Provider Demographics
NPI:1730116120
Name:BRANTLEY COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:BRANTLEY 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:PO BOX 603
Mailing Address - Street 2:
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-0603
Mailing Address - Country:US
Mailing Address - Phone:912-462-6165
Mailing Address - Fax:912-462-7655
Practice Address - Street 1:173 FLORIDA AVENUE
Practice Address - Street 2:
Practice Address - City:NAHUNTA
Practice Address - State:GA
Practice Address - Zip Code:31553-6053
Practice Address - Country:US
Practice Address - Phone:912-462-6165
Practice Address - Fax:912-462-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000453098DMedicaid
GA000052027EMedicaid
GA000777774AMedicaid
GA000457784DMedicaid
GA000453098DMedicaid
GA600002575Medicare ID - Type UnspecifiedRAILROAD BILLING #
GAGRP3494Medicare ID - Type UnspecifiedCOUNTY MDCR BILLING #