Provider Demographics
NPI:1851430821
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:SOUTHWEST VIRGINIA CHILD DEVELOPMENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-328-8000
Mailing Address - Street 1:190 BEECH ST
Mailing Address - Street 2:STE 102
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3623
Mailing Address - Country:US
Mailing Address - Phone:276-386-1312
Mailing Address - Fax:276-386-2116
Practice Address - Street 1:190 BEECH STREET
Practice Address - Street 2:STE 102
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:25251-3623
Practice Address - Country:US
Practice Address - Phone:276-386-1312
Practice Address - Fax:276-386-2116
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346218914Medicare UPIN