MEDICARE: COMMONWEALTH OF VIRGINIASTATE BOARD OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720031180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIASTATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 6
Second Line	:
City	:	NEW CASTLE
State	:	VA
Zip	:	24127-0006
Country	:	US
Telephone Number	:	540-864-5136
Fax Number	:	540-864-6454

Provider Business Practice Location Address
First Line	:	161 MAIN STREET
Second Line	:
City	:	NEW CASTLE
State	:	VA
Zip	:	24127-0006
Country	:	US
Telephone Number	:	540-864-5136
Fax Number	:	540-864-6454

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MS. VIVIAN PENN-TIMITY
Credential	:
Telephone Number	:	540-204-9718

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/20/2012

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