Healthcare Provider Details

I. General information

NPI: 1891113155
Provider Name (Legal Business Name): TIDEWATER REHABILITATION MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 FIRST COLONIAL RD SUITE 206
VIRGINIA BEACH VA
23454-2418
US

IV. Provider business mailing address

1120 FIRST COLONIAL RD SUITE 206
VIRGINIA BEACH VA
23454-2418
US

V. Phone/Fax

Practice location:
  • Phone: 757-496-2325
  • Fax: 757-496-1942
Mailing address:
  • Phone: 757-496-2325
  • Fax: 757-496-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101053621
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101053621
License Number StateVA

VIII. Authorized Official

Name: MR. STEPHEN WALTER KAYOTA
Title or Position: SOLE OWNER/AUTHORIZE OFFICIAL
Credential: M.D.
Phone: 757-496-2325