Healthcare Provider Details

I. General information

NPI: 1992244172
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206 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: 434-517-8627
  • Fax: 434-517-8080
Mailing address:
  • Phone: 434-517-3547
  • Fax: 434-517-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State

VIII. Authorized Official

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