MEDICARE: COMMONWEALTH OF VIRGINIA STATE 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

General Provider Information

NPI Number	:	1306948112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	7501 ADKINS RD
Second Line	:
City	:	CHARLES CITY
State	:	VA
Zip	:	23030-3020
Country	:	US
Telephone Number	:	804-829-2490
Fax Number	:	804-829-6702

Provider Business Practice Location Address
First Line	:	7501 ADKINS RD
Second Line	:
City	:	CHARLES CITY
State	:	VA
Zip	:	23030-3020
Country	:	US
Telephone Number	:	804-829-2490
Fax Number	:	804-829-6702

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	MRS. CAROL LIEN
Credential	:
Telephone Number	:	804-829-2490

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	08/22/2008

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