Provider Demographics
NPI:1689603979
Name:PIERCE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:PIERCE COUNTY BOARD OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSO
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-2042
Mailing Address - Street 1:715 WARE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-1723
Mailing Address - Country:US
Mailing Address - Phone:912-449-2032
Mailing Address - Fax:912-449-0409
Practice Address - Street 1:715 WARE ST
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-1723
Practice Address - Country:US
Practice Address - Phone:912-449-2032
Practice Address - Fax:912-449-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000453098NMedicaid
GA000457784NMedicaid
GA000331163BMedicaid
GA000442967OMedicaid
GA000052027MMedicaid
GA000453098NMedicaid
GAFLU131Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #
GA000442967OMedicaid