Provider Demographics
NPI:1295219210
Name:WESTERN TIDEWATER FREE CLINIC INC
Entity Type:Organization
Organization Name:WESTERN TIDEWATER FREE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-923-1060
Mailing Address - Street 1:2019 MEADE PKWY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4259
Mailing Address - Country:US
Mailing Address - Phone:757-923-1060
Mailing Address - Fax:757-923-1068
Practice Address - Street 1:2019 MEADE PKWY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-923-1060
Practice Address - Fax:757-923-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty