Healthcare Provider Details

I. General information

NPI: 1598928277
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 WILBORN AVE SUITE C
SOUTH BOSTON VA
24592
US

IV. Provider business mailing address

P.O. BOX 860
SOUTH BOSTON VA
24592
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-8893
  • Fax: 434-517-3887
Mailing address:
  • Phone: 434-517-3513
  • Fax: 434-517-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0101037012
License Number StateVA

VIII. Authorized Official

Name: CECIL HAZELWOOD
Title or Position: MANAGER/SDHC)
Credential:
Phone: 434-517-3515