NPIMap

Organization Active NPI

Southern Dominion Health System, Inc.

Doing business as Lunenburg Medical Center

  • Federally Qualified Health Center (FQHC)
  • Victoria, VA
National Provider Identifier
1497969091
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
Lunenburg Medical Center
Practice address
1508 K-V Road
Victoria, VA 23974
Phone
(434) 696-2165
Fax
(434) 696-1378
NPI assigned
May 10, 2007
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU
Federally Qualified Health Center (FQHC) 261QF0400X VA Primary

Addresses

Primary practice location

1508 K-V Road
Victoria, VA 23974

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
007691084MedicaidVA

Other names 1

  • Lunenburg Medical Center 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
O20080520000768 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 1497969091. Details of each certification follow.

Federally qualified health center certification: CCN 491821

Legal name
SOUTHERN DOMINION HEALTH SYSTEM INC
Doing business as
LUNENBURG MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 1, 1992
Last certification
Jan 1, 1992
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1985 in VA
Enrollment address
1508 K V Rd
Victoria, VA 23974-2624

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

Ownership & related parties

All disclosed owners & managing parties 14

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 DirectorChairman Apr 18, 1994
Beatrice O Head Individual Corporate DirectorBoard Member Nov 15, 2010
Anne G Gaulding Individual Corporate DirectorBoard Member Sep 21, 2009
Mary H Stewart Individual Corporate DirectorBoard Member Apr 15, 2019
Harold M Walker Individual Corporate DirectorBoard Member Jul 16, 2001
Robert E Clement Individual Corporate DirectorBoard Member Jan 17, 2000
April L King Individual Corporate OfficerCeo Apr 19, 2022
Angela B Wilson Individual Corporate DirectorSecretary Sep 16, 2002
Wanda S Hill Individual Corporate DirectorBoard Member Nov 15, 2010
Jill W Seamans Individual Corporate DirectorCeo Aug 13, 2015
W-2 Managing EmployeeCeo Aug 13, 2015
Luther M Drummard Individual Corporate DirectorBoard Member Sep 13, 2006
Eileen E Duffy Individual Corporate DirectorBoard Member Jun 19, 1995
Rebecca P Reitz Individual Corporate DirectorBoard Member Aug 20, 2018
April S Long Individual Corporate DirectorBoard Member Aug 20, 2018

Practitioners & affiliated clinicians

Practitioners 26

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.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1178755200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707264000000",
    "number": "1497969091",
    "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": "434-696-1378"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1508 K-V ROAD",
            "city": "VICTORIA",
            "state": "VA",
            "postal_code": "23974",
            "telephone_number": "434-696-2165",
            "fax_number": "434-696-1378"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "enumeration_date": "2007-05-10",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "VA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "007691084",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lunenburg Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Victoria, VA

Sources for this page

Verify at the official NPI Registry.