Provider Demographics
NPI:1720053648
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:FRANKLIN CITY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-514-4765
Mailing Address - Street 1:200 FAIRVIEW AVE
Mailing Address - Street 2:PO BOX 595
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-0595
Mailing Address - Country:US
Mailing Address - Phone:757-562-6109
Mailing Address - Fax:757-562-2630
Practice Address - Street 1:200 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1216
Practice Address - Country:US
Practice Address - Phone:757-562-6109
Practice Address - Fax:757-562-2630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4976134Medicaid
VA008770336Medicaid
VA008700672Medicaid
VA008700672Medicaid