Healthcare Provider Details

I. General information

NPI: 1124310446
Provider Name (Legal Business Name): SOUTHERN DOMINION HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13855 COURTHOUSE ROAD
DINWIDDIE VA
23841
US

IV. Provider business mailing address

PO BOX 70
VICTORIA VA
23974-0070
US

V. Phone/Fax

Practice location:
  • Phone: 804-469-3731
  • Fax: 804-469-5307
Mailing address:
  • Phone: 434-696-2165
  • Fax: 434-696-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateVA

VIII. Authorized Official

Name: MRS. JILL W SEAMANS
Title or Position: CFO
Credential:
Phone: 434-696-2165