Healthcare Provider Details

I. General information

NPI: 1104879568
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ACADEMY STREET
FINCASTLE VA
24090-0220
US

IV. Provider business mailing address

PO BOX 220
FINCASTLE VA
24090-0220
US

V. Phone/Fax

Practice location:
  • Phone: 540-473-8240
  • Fax: 540-473-8242
Mailing address:
  • Phone: 540-473-8240
  • Fax: 540-473-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. VIVIAN PENN-TIMITY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 540-204-9718