Healthcare Provider Details

I. General information

NPI: 1972750420
Provider Name (Legal Business Name): TIDEWATER WEIGHT LOSS AND WELLNESS CENTERS,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2468 E LITTLE CREEK RD SUITE B
NORFOLK VA
23518-3231
US

IV. Provider business mailing address

2468 E LITTLE CREEK RD SUITE B
NORFOLK VA
23518-3231
US

V. Phone/Fax

Practice location:
  • Phone: 757-480-5673
  • Fax: 757-480-2333
Mailing address:
  • Phone: 757-480-5673
  • Fax: 757-480-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0101231458
License Number StateVA

VIII. Authorized Official

Name: MS. SUSAN MURRAY CHALENDER
Title or Position: QWNER/PRESIDENT
Credential:
Phone: 757-480-5673