Healthcare Provider Details

I. General information

NPI: 1679247571
Provider Name (Legal Business Name): TIDAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LOUIS LN.
SOUTHPORT ME
04576
US

IV. Provider business mailing address

PO BOX 395
SOUTHPORT ME
04576-0395
US

V. Phone/Fax

Practice location:
  • Phone: 513-739-2422
  • Fax:
Mailing address:
  • Phone: 513-739-2422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: EDEN CLIMO
Title or Position: CEO, PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 513-739-2422