1992039499 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992039499 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:
1992039499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1502 WILLIAMSON RD NE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24012-5130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-283-5050
Provider Business Mailing Address Fax Number:
540-857-7316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1502 WILLIAMSON RD NE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24012-5130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-283-5050
Provider Business Practice Location Address Fax Number:
540-857-7316
Provider Enumeration Date:
09/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PENN-TIMITY
Authorized Official First Name:
VIVIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER C
Authorized Official Telephone Number:
540-283-5050

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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