=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679247571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDAL WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2021
-----------------------------------------------------
Last Update Date | 08/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 LOUIS LN.
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-739-2422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 395
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04576-0395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-739-2422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, PHYSICAL THERAPIST
-----------------------------------------------------
Name | EDEN CLIMO
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 513-739-2422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------