Provider Demographics
NPI:1790894780
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:WISE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-328-8000
Mailing Address - Street 1:134 ROBERTS AVE SW
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-5800
Mailing Address - Country:US
Mailing Address - Phone:276-328-8000
Mailing Address - Fax:276-376-1020
Practice Address - Street 1:134 ROBERTS AVE SW
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-5800
Practice Address - Country:US
Practice Address - Phone:276-328-8000
Practice Address - Fax:276-376-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975049Medicaid
VA600000529OtherRAILROAD MEDICARE
VAB09328Medicare UPIN
VA004975049Medicaid
VA600000529OtherRAILROAD MEDICARE
VAS96374Medicare UPIN
VAC09066Medicare PIN