=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164613543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDEWATER HEART LABORATORIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 08/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2116 EXECUTIVE DR
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-224-4233
-----------------------------------------------------
Fax | 757-224-4955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 EXECUTIVE DR SUITE 1B
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-825-4260
-----------------------------------------------------
Fax | 757-825-4265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTATOR
-----------------------------------------------------
Name | MRS. BONNIE HERRING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-825-4260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------