MEDICARE: COFFEE COUNTY 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316976699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COFFEE COUNTY BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	1003 SHIRLEY AVE
Second Line	:
City	:	DOUGLAS
State	:	GA
Zip	:	31533-2123
Country	:	US
Telephone Number	:	912-389-4586
Fax Number	:	913-389-4590

Provider Business Practice Location Address
First Line	:	1003 SHIRLEY AVE
Second Line	:
City	:	DOUGLAS
State	:	GA
Zip	:	31533-2123
Country	:	US
Telephone Number	:	912-389-4586
Fax Number	:	913-389-4590

Authorized Official
Title or Position	:	PSO
Name	:	STARLA SUTTON
Credential	:
Telephone Number	:	912-338-5263

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	12/11/2012

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Directions to “COFFEE COUNTY BOARD OF HEALTH ” Practice Location

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