Provider Demographics
NPI:1053386979
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:26022 ADMINISTRATIVE CENTER DRIVE
Mailing Address - Street 2:PO BOX 09
Mailing Address - City:COURTLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23837-0009
Mailing Address - Country:US
Mailing Address - Phone:757-653-3040
Mailing Address - Fax:757-653-0834
Practice Address - Street 1:26022 ADMINISTRATIVE CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:COURTLAND
Practice Address - State:VA
Practice Address - Zip Code:23837-0009
Practice Address - Country:US
Practice Address - Phone:757-653-3040
Practice Address - Fax:757-653-0834
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
VA8450714Medicaid
VA008700681Medicaid
VA008770280Medicaid
VA497229Medicaid
VA4975952Medicaid
VA4975952Medicaid