Provider Demographics
NPI:1982679874
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:ISLE OF WIGHT 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 1:919 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-1715
Mailing Address - Country:US
Mailing Address - Phone:757-357-4177
Mailing Address - Fax:757-357-2838
Practice Address - Street 1:919 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-1715
Practice Address - Country:US
Practice Address - Phone:757-357-4177
Practice Address - Fax:757-357-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008770310Medicaid
VA8450811Medicaid
4975618OtherCLINIC
VA008700656OtherPERSONAL CARE
VA008700656OtherPERSONAL CARE