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General NPI Number Information
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NPI Number | 1891137048
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Entity Type | Organization
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Legal Business Name | TIDEWATER FOOT CENTER LLC
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Dates
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Enumeration Date | 07/29/2013
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Last Update Date | 12/09/2013
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Provider Practice Location Address
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Address Line | 126 MONARCH DR
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City | NEWPORT NEWS
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State | VA
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Zip | 23602-6884
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Country | US
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Telephone | 757-597-1520
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Fax | 757-597-7099
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Provider Business Mailing Address
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Address Line | 11747 JEFFERSON AVE STE 2A
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-4402
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Country | US
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Telephone | 757-597-7699
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Fax | 757-597-7099
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Authorized Official
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Title or Position | SOLE OWNER
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Name | STEVEN THOU PRAK
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Credential | D.P.M
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Telephone | 757-597-7699
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 0103301081
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License Number State | VA
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