Provider Demographics
NPI:1831288679
Name:POLK COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:POLK COUNTY BOARD OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:C. WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-295-6704
Mailing Address - Street 1:320 WATER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKMART
Mailing Address - State:GA
Mailing Address - Zip Code:30153-2669
Mailing Address - Country:US
Mailing Address - Phone:770-684-1385
Mailing Address - Fax:770-684-8231
Practice Address - Street 1:320 WATER ST
Practice Address - Street 2:
Practice Address - City:ROCKMART
Practice Address - State:GA
Practice Address - Zip Code:30153-2669
Practice Address - Country:US
Practice Address - Phone:770-684-1385
Practice Address - Fax:770-684-8231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025271251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAFLU186Medicare ID - Type UnspecifiedFLU BILLING