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General NPI Number Information
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NPI Number | 1033154430
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Entity Type | Organization
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Legal Business Name | LONG TERM CARE OF TIDEWATER PC
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Dates
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Enumeration Date | 06/19/2006
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Last Update Date | 11/01/2019
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Provider Practice Location Address
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Address Line | 6160 KEMPSVILLE CIR STE 325A
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City | NORFOLK
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State | VA
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Zip | 23502-3933
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Country | US
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Telephone | 757-917-5356
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Fax | 757-917-5141
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Provider Business Mailing Address
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Address Line | 110 KINGSLEY LN STE 312
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City | NORFOLK
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State | VA
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Zip | 23505-4618
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Country | US
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Telephone | 757-917-5356
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Fax | 757-917-5141
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Authorized Official
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Title or Position | CREDENTIALING
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Name | JAYNE WALTER
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Credential |
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Telephone | 757-917-5356
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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