Provider Demographics
NPI:1790791176
Name:JEWISH FAMILY SERVICE OF TIDEWATER, INCORPORATED
Entity Type:Organization
Organization Name:JEWISH FAMILY SERVICE OF TIDEWATER, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:757-321-2247
Mailing Address - Street 1:5000 CORPORATE WOODS DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4429
Mailing Address - Country:US
Mailing Address - Phone:757-321-2244
Mailing Address - Fax:757-321-2260
Practice Address - Street 1:5000 CORPORATE WOODS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4429
Practice Address - Country:US
Practice Address - Phone:757-321-2244
Practice Address - Fax:757-321-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004974891Medicaid
VA008700435Medicaid
VA011608OtherANTHEM BLUE CROSS BLUE SH
VA004974891Medicaid
VA011608OtherANTHEM BLUE CROSS BLUE SH