Provider Demographics
NPI:1871602730
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:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-328-8000
Mailing Address - Street 1:190 BEECH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3623
Mailing Address - Country:US
Mailing Address - Phone:276-386-1312
Mailing Address - Fax:276-386-2116
Practice Address - Street 1:190 BEECH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3638
Practice Address - Country:US
Practice Address - Phone:276-386-1312
Practice Address - Fax:276-386-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975201Medicaid
600001192OtherMEDICARE RAILROAD
VA4975201Medicaid
S96374Medicare UPIN
B09328Medicare UPIN
VAC09066Medicare PIN
600001192OtherMEDICARE RAILROAD