Healthcare Provider Details

I. General information

NPI: 1790999621
Provider Name (Legal Business Name): TIDEWATER LACTATION GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5741 CLEVELAND ST STE 150
VIRGINIA BEACH VA
23462-1777
US

IV. Provider business mailing address

5741 CLEVELAND ST STE 150
VIRGINIA BEACH VA
23462-1777
US

V. Phone/Fax

Practice location:
  • Phone: 757-422-5502
  • Fax: 757-455-8055
Mailing address:
  • Phone: 757-422-5502
  • Fax: 757-455-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number0001182636
License Number StateVA

VIII. Authorized Official

Name: MS. ELIZABETH IRELAND FLIGHT
Title or Position: PRESIDENT
Credential: BSN, RN, IBCLC
Phone: 757-618-6311