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General NPI Number Information
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NPI Number | 1659476752
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Entity Type | Organization
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Legal Business Name | TIDEWATER EYE CENTERS PC
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3601 COUNTY ST
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City | PORTSMOUTH
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State | VA
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Zip | 23707-3103
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Country | US
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Telephone | 757-397-7858
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Fax | 757-673-6832
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Provider Business Mailing Address
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Address Line | 3603 COUNTY ST
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City | PORTSMOUTH
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State | VA
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Zip | 23707-3103
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Country | US
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Telephone | 757-397-2020
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Fax | 757-673-6832
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Authorized Official
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Title or Position | LICENSED OPTICIAN / MANAGER
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Name | MRS. KIMBERLY ASTON
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Credential | LO
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Telephone | 757-397-7858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State | VA
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