Provider Demographics
NPI:1770653537
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:CHILD DEVELOPMENT CLINIC SOUTHSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GATELEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-766-9800
Mailing Address - Street 1:326 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4023
Mailing Address - Country:US
Mailing Address - Phone:434-766-9800
Mailing Address - Fax:434-799-5022
Practice Address - Street 1:326 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4023
Practice Address - Country:US
Practice Address - Phone:434-766-9800
Practice Address - Fax:434-799-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0049-76-100Medicaid
VA27559OtherSENTATA/OPTIMA