Provider Demographics
NPI:1952346074
Name:COFFEE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:COFFEE COUNTY BOARD OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSO
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-2042
Mailing Address - Street 1:1111 BAKER HWY W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2107
Mailing Address - Country:US
Mailing Address - Phone:912-389-4450
Mailing Address - Fax:912-389-4326
Practice Address - Street 1:1111 BAKER HWY W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2107
Practice Address - Country:US
Practice Address - Phone:912-389-4450
Practice Address - Fax:912-389-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000442967JMedicaid
GA000457784JMedicaid
GA000052027JMedicaid
GA000453098JMedicaid
GA000777598AMedicaid
GA600000734Medicare ID - Type UnspecifiedRAILROAD BILLING #
GA000442967JMedicaid
GA000453098JMedicaid