Healthcare Provider Details

I. General information

NPI: 1295253987
Provider Name (Legal Business Name): TIDEWATER DIAGNOSTIC CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 COLLEY AVE
NORFOLK VA
23508-2166
US

IV. Provider business mailing address

524 NORMANDY ST
PORTSMOUTH VA
23701-4312
US

V. Phone/Fax

Practice location:
  • Phone: 877-366-1133
  • Fax: 757-257-0309
Mailing address:
  • Phone: 757-589-2673
  • Fax: 757-966-7954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number49D2135077
License Number StateVA

VIII. Authorized Official

Name: CANDIDA DENISE SINGLETON
Title or Position: OWNER
Credential:
Phone: 877-366-1133