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General NPI Number Information
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NPI Number | 1487476628
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Entity Type | Organization
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Legal Business Name | DOMINION HEALTH MEDICAL ASSOC
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Dates
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Enumeration Date | 10/29/2024
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 2204 WILBORN AVE
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1645
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Country | US
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Telephone | 434-517-3403
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Fax | 434-517-3686
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Provider Business Mailing Address
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Address Line | 2204 WILBORN AVE
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1645
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Country | US
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Telephone | 434-517-3403
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Fax | 434-517-3686
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Authorized Official
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Title or Position | DIRECTOR
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Name | DORIS PRINCE
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Credential |
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Telephone | 757-983-5475
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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