Healthcare Provider Details

I. General information

NPI: 1922041177
Provider Name (Legal Business Name): WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 BLYTHEWOOD LN
SUFFOLK VA
23434-2804
US

IV. Provider business mailing address

7025 HARBOUR VIEW BLVD STE 119
SUFFOLK VA
23435-2762
US

V. Phone/Fax

Practice location:
  • Phone: 757-255-7127
  • Fax:
Mailing address:
  • Phone: 757-966-2805
  • Fax: 757-673-2586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIOS PERATSAKIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 757-966-2805