Provider Demographics
NPI:1790937589
Name:TIDEWATER HOMESPEC, LLC
Entity Type:Organization
Organization Name:TIDEWATER HOMESPEC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:O
Authorized Official - Last Name:LONGMORE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:757-409-1969
Mailing Address - Street 1:1024 PATRICK HENRY WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4826
Mailing Address - Country:US
Mailing Address - Phone:757-409-1969
Mailing Address - Fax:
Practice Address - Street 1:1024 PATRICK HENRY WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-4826
Practice Address - Country:US
Practice Address - Phone:757-409-1969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705096060332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies