NPIMap

Organization Active NPI

Southern Dominion Health System, Inc.

Doing business as SDHS Counseling & Behavioral Services

  • Federally Qualified Health Center (FQHC)
  • Victoria, VA
National Provider Identifier
1104069996
Registry record updated Feb 7, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHERN DOMINION HEALTH SYSTEM, INC.
Doing business as
SDHS Counseling & Behavioral Services
Practice address
1508 K V Rd
Victoria, VA 23974-2624
Phone
(434) 696-2319
Fax
(434) 696-2326
NPI assigned
Apr 9, 2009
Last updated
Feb 7, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTHERN DOMINION HEALTH SYSTEM, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 7, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
April King
Title
Ceo
Phone
(434) 696-2165

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X VA
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X VA
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X

Addresses

Primary practice location

1508 K V Rd
Victoria, VA 23974-2624

Mailing address

PO Box 70
Victoria, VA 23974-0070
Phone (434) 696-2165

Other practice location 1

13855 Courthouse Rd
Dinwiddie, VA 23841-2254
Phone (804) 469-3731

Other names 1

  • SDHS Counseling & Behavioral Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040611000631 VA Part B Supplier - Clinic/Group Practice 0648188755 Receives reassigned benefits from 25 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Amelia, VA; Dinwiddle, VA; Emporia, VA; Victoria, VA
O20090518000439 VA Part A Provider - Federally Qualified Health Center (FQHC) 0648188755 Practice locations: Victoria, VA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104069996. Details of each certification follow.

Federally qualified health center certification: CCN 491895

Legal name
SOUTHERN DOMINION HEALTH SYSTEM INC
Doing business as
SDHS COUNSELING AND BEHAVIORAL SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 14, 2009
Last certification
Jul 14, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1985 in VA
Enrollment address
1685 K-V Rd
Victoria, VA 23974-0070

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Amelia Health Care Cent

Locations

13855 Courthouse Rd
Dinwiddie, VA 23841
Phone (804) 469-3731

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Edward H Jeter Individual Corporate DirectorBoard Member Apr 18, 1994 8%
Beatrice O Head Individual Corporate DirectorBoard Member Nov 15, 2010 8%
Michelle Mitchell Individual Corporate DirectorBoard Member Jul 16, 2018 8%
Anne G Gaulding Individual Corporate DirectorBoard Member Sep 21, 2009 8%
Harold M Walker Individual Corporate DirectorBoard Member Jul 16, 2001 8%
Robert E Clement Individual Corporate DirectorBoard Member Jan 17, 2000 8%
Angela B Wilson Individual Corporate DirectorBoard Member Sep 16, 2002 8%
Wanda S Hill Individual Corporate DirectorBoard Member Nov 15, 2010 8%
Jill W Seamans Individual Corporate OfficerCeo Aug 13, 2015
W-2 Managing EmployeeCeo Aug 13, 2018
Luther M Drummard Individual Corporate DirectorBoard Member Sep 13, 2006 8%
Eileen E Duffy Individual Corporate DirectorBoard Member Jun 19, 1995 8%
Rebecca P Reitz Individual Corporate DirectorBoard Member Aug 20, 2018 8%
April S Long Individual Corporate DirectorBoard Member Jul 16, 2018 8%

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1239235200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707264000000",
    "number": "1104069996",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 70",
            "city": "VICTORIA",
            "state": "VA",
            "postal_code": "239740070",
            "telephone_number": "434-696-2165",
            "fax_number": "434-696-1557"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1508 K V RD",
            "city": "VICTORIA",
            "state": "VA",
            "postal_code": "239742624",
            "telephone_number": "434-696-2319",
            "fax_number": "434-696-2326"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "13855 Courthouse Rd",
            "address_purpose": "LOCATION",
            "city": "Dinwiddie",
            "state": "VA",
            "postal_code": "238412254",
            "country_code": "US",
            "telephone_number": "804-469-3731",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "enumeration_date": "2009-04-09",
        "last_updated": "2024-02-07",
        "certification_date": "2024-02-07",
        "status": "A",
        "authorized_official_last_name": "KING",
        "authorized_official_first_name": "APRIL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "434-696-2165"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "VA",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "VA",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SDHS Counseling & Behavioral Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Victoria, VA

Sources for this page

Verify at the official NPI Registry.