Provider Demographics
NPI:1275152456
Name:TIDAL BORE RESOURCE CENTER
Entity Type:Organization
Organization Name:TIDAL BORE RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-782-8369
Mailing Address - Street 1:2440 E TUDOR RD STE 240
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1185
Mailing Address - Country:US
Mailing Address - Phone:907-782-8369
Mailing Address - Fax:
Practice Address - Street 1:14251 JARVI DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3945
Practice Address - Country:US
Practice Address - Phone:907-782-8369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty