Healthcare Provider Details

I. General information

NPI: 1710293212
Provider Name (Legal Business Name): TIDEWATER INTEGRATIVE HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 NORTH NEWTOWN RD
VIRGINIA BEACH VA
23462-1116
US

IV. Provider business mailing address

802 NORTH NEWTOWN RD
VIRGINIA BEACH VA
23462-1116
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-0606
  • Fax: 757-497-0411
Mailing address:
  • Phone: 757-497-0606
  • Fax: 757-497-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101035294
License Number StateVA

VIII. Authorized Official

Name: WALTER KEVIN HUNT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 757-497-0606