1558390302 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Table of content: (NPI 1558390302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558390302 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558390302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20103 PRINCETON RD
Provider Second Line Business Mailing Address:
P.O. BOX 13435
Provider Business Mailing Address City Name:
SUSSEX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-246-8611
Provider Business Mailing Address Fax Number:
434-246-8610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20103 PRINCETON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUSSEX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-246-8611
Provider Business Practice Location Address Fax Number:
434-246-8610
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RANKIN
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DISTRICT HEALTH DIRECTOR
Authorized Official Telephone Number:
804-863-1652

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42517 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 41198 . This is a "OPTIMA/SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004975995 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 266465 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 85732 . This is a "VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 42577 . This is a "CARENET" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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