MEDICARE: TIDEWATER PCA TRAINING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1235585761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER PCA TRAINING

Provider Business Mailing Address
First Line	:	4605 PEMBROKE LAKE CIR
Second Line	:	SUITE 303
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6434
Country	:	US
Telephone Number	:	757-675-7270
Fax Number	:

Provider Business Practice Location Address
First Line	:	4605 PEMBROKE LAKE CIR
Second Line	:	SUITE 303
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6434
Country	:	US
Telephone Number	:	757-675-7270
Fax Number	:

Authorized Official
Title or Position	:	OWNER DIRECTOR
Name	:	NICHOLETTE CADORE
Credential	:
Telephone Number	:	757-675-7270

Provider Enumeration Date	:	05/13/2016
Last Update Date	:	05/13/2016

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Directions to “TIDEWATER PCA TRAINING ” Practice Location

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