Healthcare Provider Details

I. General information

NPI: 1104247733
Provider Name (Legal Business Name): TIDEWATER HOME MODIFIERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2013
Last Update Date: 12/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 MARINA CT
CHESAPEAKE VA
23320-3402
US

IV. Provider business mailing address

206 MARINA CT
CHESAPEAKE VA
23320-3402
US

V. Phone/Fax

Practice location:
  • Phone: 757-618-4064
  • Fax:
Mailing address:
  • Phone: 757-618-4064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name: MR. CHESTLEY THOMAS COWLING JR.
Title or Position: OWNER/MEMBER
Credential:
Phone: 757-618-4064