MEDICARE: TIDEWATER HOMESPEC, LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies	2705096060	VA

General Provider Information

NPI Number	:	1790937589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER HOMESPEC, LLC

Provider Business Mailing Address
First Line	:	1024 PATRICK HENRY WAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-4826
Country	:	US
Telephone Number	:	757-409-1969
Fax Number	:

Provider Business Practice Location Address
First Line	:	1024 PATRICK HENRY WAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-4826
Country	:	US
Telephone Number	:	757-409-1969
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. CLARENCE O LONGMORE III
Credential	:
Telephone Number	:	757-409-1969

Provider Enumeration Date	:	10/13/2008
Last Update Date	:	10/13/2008

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