Healthcare Provider Details

I. General information

NPI: 1568933182
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AUBREYS LOOP
SOUTH BOSTON VA
24592-5054
US

IV. Provider business mailing address

PO BOX 860
SOUTH BOSTON VA
24592-0860
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

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