Provider Demographics
NPI:1790823292
Name:SPINE CARE OF TIDEWATER PC
Entity Type:Organization
Organization Name:SPINE CARE OF TIDEWATER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WESTBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-873-8483
Mailing Address - Street 1:11872 CANON BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4239
Mailing Address - Country:US
Mailing Address - Phone:757-873-8483
Mailing Address - Fax:757-873-1150
Practice Address - Street 1:11872 CANON BLVD STE D
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4239
Practice Address - Country:US
Practice Address - Phone:757-873-8483
Practice Address - Fax:757-873-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10140Medicare PIN