Organization
SOUTH BOSTON PEDIATRICS, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. NONNA LYN EBALO M.D. (PRESIDENT)
(434) 470-3489
Entity
Organization
Contact information
Practice address
2202 BEECHMONT RD, SOUTH BOSTON, VA 24592-1614
(434) 572-3635
Mailing address
PO BOX 774, SOUTH BOSTON, VA 24592-0774
(434) 572-3635
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
0101232220
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01046086
—
VA
Enumeration date
09/05/2012
Last updated
09/05/2012
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