Provider Demographics
NPI:1831109032
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:BUENA VISTA ROCKBRIDGE HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE SERVICE SUPERVISOR SENIOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HABEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-332-7830
Mailing Address - Street 1:2270 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24416-3122
Mailing Address - Country:US
Mailing Address - Phone:540-261-2149
Mailing Address - Fax:540-261-1661
Practice Address - Street 1:2270 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:VA
Practice Address - Zip Code:24416-3122
Practice Address - Country:US
Practice Address - Phone:540-261-2149
Practice Address - Fax:540-261-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021588251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004976070Medicaid
VA004976070Medicaid