Healthcare Provider Details

I. General information

NPI: 1912706722
Provider Name (Legal Business Name): TIDAL RIVER PELVIC HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 MIDDLE RD
WOOLWICH ME
04579-4303
US

IV. Provider business mailing address

963 MIDDLE RD
WOOLWICH ME
04579-4303
US

V. Phone/Fax

Practice location:
  • Phone: 207-798-9770
  • Fax:
Mailing address:
  • Phone: 207-798-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANET E EICH
Title or Position: OWNER
Credential: OTR/L
Phone: 207-798-9770