Provider Demographics
NPI:1720031180
Name:COMMONWEALTH OF VIRGINIASTATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIASTATE BOARD OF HEALTH
Other - Org Name:CRAIG COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN-TIMITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-204-9718
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24127-0006
Mailing Address - Country:US
Mailing Address - Phone:540-864-5136
Mailing Address - Fax:540-864-6454
Practice Address - Street 1:161 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:VA
Practice Address - Zip Code:24127-0006
Practice Address - Country:US
Practice Address - Phone:540-864-5136
Practice Address - Fax:540-864-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975413Medicaid
VA600000048Medicare PIN