Provider Demographics
NPI:1104069996
Name:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Entity type:Organization
Organization Name:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-696-2165
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23974-0070
Mailing Address - Country:US
Mailing Address - Phone:434-696-2165
Mailing Address - Fax:434-696-1557
Practice Address - Street 1:1508 K V RD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:VA
Practice Address - Zip Code:23974-2624
Practice Address - Country:US
Practice Address - Phone:434-696-2319
Practice Address - Fax:434-696-2326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-09
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QM0801X, 261QF0400X
261QM0801X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA491895Medicare Oscar/Certification