Provider Demographics
NPI:1740231067
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:ROANOKE COUNTY/SALEM 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 1144
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-1144
Mailing Address - Country:US
Mailing Address - Phone:540-387-5530
Mailing Address - Fax:540-387-5524
Practice Address - Street 1:105 E CALHOUN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3838
Practice Address - Country:US
Practice Address - Phone:540-387-5530
Practice Address - Fax:540-387-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975031Medicaid
VA4975031Medicaid