Provider Demographics
NPI:1619172186
Name:TIDEWATER COMPREHENSIVE REHABILITATION, PLLC
Entity Type:Organization
Organization Name:TIDEWATER COMPREHENSIVE REHABILITATION, PLLC
Other - Org Name:TIDEWATER REHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:757-622-8181
Mailing Address - Street 1:400 GRESHAM DR
Mailing Address - Street 2:STE 712
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-622-8181
Mailing Address - Fax:757-622-8088
Practice Address - Street 1:400 GRESHAM DR
Practice Address - Street 2:STE 712
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-622-8181
Practice Address - Fax:757-622-8088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty