Healthcare Provider Details

I. General information

NPI: 1497969091
Provider Name (Legal Business Name): SOUTHERN DOMINION HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 K-V ROAD
VICTORIA VA
23974
US

IV. Provider business mailing address

PO BOX 70
VICTORIA VA
23974-0070
US

V. Phone/Fax

Practice location:
  • Phone: 434-696-2165
  • Fax: 434-696-1378
Mailing address:
  • Phone: 434-696-2165
  • Fax: 434-696-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateVA

VIII. Authorized Official

Name: APRIL KING
Title or Position: CEO
Credential:
Phone: 434-696-2165