Healthcare Provider Details

I. General information

NPI: 1033154430
Provider Name (Legal Business Name): LONG TERM CARE OF TIDEWATER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 KEMPSVILLE CIR STE 325A
NORFOLK VA
23502-3933
US

IV. Provider business mailing address

110 KINGSLEY LN STE 312
NORFOLK VA
23505-4618
US

V. Phone/Fax

Practice location:
  • Phone: 757-917-5356
  • Fax: 757-917-5141
Mailing address:
  • Phone: 757-917-5356
  • Fax: 757-917-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAYNE WALTER
Title or Position: CREDENTIALING
Credential:
Phone: 757-917-5356