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General NPI Number Information
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NPI Number | 1295253987
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Entity Type | Organization
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Legal Business Name | TIDEWATER DIAGNOSTIC CONSULTANTS, LLC
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Dates
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Enumeration Date | 09/01/2017
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Last Update Date | 09/01/2017
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Provider Practice Location Address
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Address Line | 5215 COLLEY AVE
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City | NORFOLK
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State | VA
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Zip | 23508-2166
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Country | US
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Telephone | 877-366-1133
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Fax | 757-257-0309
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Provider Business Mailing Address
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Address Line | 524 NORMANDY ST
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City | PORTSMOUTH
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State | VA
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Zip | 23701-4312
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Country | US
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Telephone | 757-589-2673
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Fax | 757-966-7954
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Authorized Official
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Title or Position | OWNER
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Name | CANDIDA DENISE SINGLETON
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Credential |
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Telephone | 877-366-1133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 49D2135077
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License Number State | VA
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