Provider Demographics
NPI:1710087960
Name:POLK COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:POLK COUNTY BOARD OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:C. WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-295-6704
Mailing Address - Street 1:125 E WARE ST
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-3051
Mailing Address - Country:US
Mailing Address - Phone:770-749-2270
Mailing Address - Fax:770-749-2298
Practice Address - Street 1:125 E WARE ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-3051
Practice Address - Country:US
Practice Address - Phone:770-749-2270
Practice Address - Fax:770-749-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000699212AMedicaid
GAFLU186Medicare ID - Type UnspecifiedFLU BILLING