Healthcare Provider Details

I. General information

NPI: 1184874166
Provider Name (Legal Business Name): TIDEWATER HOME HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 CORPORATION LN SUITE 270
VIRGINIA BEACH VA
23462-3262
US

IV. Provider business mailing address

4445 CORPORATION LN SUITE 270
VIRGINIA BEACH VA
23462-3262
US

V. Phone/Fax

Practice location:
  • Phone: 757-213-6910
  • Fax: 757-213-6801
Mailing address:
  • Phone: 757-213-6910
  • Fax: 757-213-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: GLENN M GAINEY
Title or Position: PRESIDENT
Credential:
Phone: 757-213-6910