Provider Demographics
NPI:1093110223
Name:TIDEWATER HEARING CENTER
Entity Type:Organization
Organization Name:TIDEWATER HEARING CENTER
Other - Org Name:MIRACLE EAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:IVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-825-9477
Mailing Address - Street 1:2555 COVE POINT PL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3271
Mailing Address - Country:US
Mailing Address - Phone:757-825-9477
Mailing Address - Fax:757-825-9139
Practice Address - Street 1:5200 MERCURY BLVD
Practice Address - Street 2:SEARS, SUITE 100
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-1445
Practice Address - Country:US
Practice Address - Phone:757-825-9477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA124122332B00000X
VA03231332B00000X
VA14763800005200332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies