Healthcare Provider Details

I. General information

NPI: 1720053648
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FAIRVIEW AVE
FRANKLIN VA
23851-1216
US

IV. Provider business mailing address

200 FAIRVIEW AVE PO BOX 595
FRANKLIN VA
23851-0595
US

V. Phone/Fax

Practice location:
  • Phone: 757-562-6109
  • Fax: 757-562-2630
Mailing address:
  • Phone: 757-562-6109
  • Fax: 757-562-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA YVETTE TILLERY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 757-514-4765