Provider Demographics
NPI:1124310446
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:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SEAMANS
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 1:13855 COURTHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841
Practice Address - Country:US
Practice Address - Phone:804-469-3731
Practice Address - Fax:804-469-5307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
VA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)