Healthcare Provider Details

I. General information

NPI: 1255771770
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 WILBORN AVE
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: 434-517-3529
  • 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 Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CECIL HAZELWOOD
Title or Position: MANAGER (SDHG)
Credential:
Phone: 434-517-3590