Healthcare Provider Details

I. General information

NPI: 1720638992
Provider Name (Legal Business Name): TIDEWATER NUTRITION & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 COVE ST
PORTLAND ME
04101-2514
US

IV. Provider business mailing address

52 COVE ST
PORTLAND ME
04101-2514
US

V. Phone/Fax

Practice location:
  • Phone: 207-358-0154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINE TAYLOR
Title or Position: REGISTERED DIETITIAN/OWNER
Credential: MS, RDN, LD
Phone: 207-358-0154