Provider Demographics
NPI:1679247571
Name:TIDAL WELLNESS LLC
Entity Type:Organization
Organization Name:TIDAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLIMO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:513-739-2422
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04576-0395
Mailing Address - Country:US
Mailing Address - Phone:513-739-2422
Mailing Address - Fax:
Practice Address - Street 1:14 LOUIS LN.
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:ME
Practice Address - Zip Code:04576
Practice Address - Country:US
Practice Address - Phone:513-739-2422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty