Healthcare Provider Details

I. General information

NPI: 1316188733
Provider Name (Legal Business Name): TIDEWATER HEALTHCARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2009
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 PROGRESSIVE DR SUITE 102
CHESAPEAKE VA
23320-2848
US

IV. Provider business mailing address

1214 PROGRESSIVE DR SUITE 102
CHESAPEAKE VA
23320-2848
US

V. Phone/Fax

Practice location:
  • Phone: 757-227-4047
  • Fax: 757-227-4109
Mailing address:
  • Phone: 757-227-4047
  • Fax: 757-227-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES MICHAEL WALTON
Title or Position: PRESIDENT
Credential:
Phone: 757-227-4047