Healthcare Provider Details

I. General information

NPI: 1881700169
Provider Name (Legal Business Name): HALIFAX HEART CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 WILBORN AVE
SOUTH BOSTON VA
24592-1662
US

IV. Provider business mailing address

PO BOX 1115
SOUTH BOSTON VA
24592-1115
US

V. Phone/Fax

Practice location:
  • Phone: 434-572-8977
  • Fax: 434-572-2510
Mailing address:
  • Phone: 434-517-3515
  • Fax: 434-572-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateVA

VIII. Authorized Official

Name: CECIL F HAZELWOOD
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 434-517-3515