Provider Demographics
NPI:1790999621
Name:TIDEWATER LACTATION GROUP, INC.
Entity Type:Organization
Organization Name:TIDEWATER LACTATION GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:IRELAND
Authorized Official - Last Name:FLIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN, IBCLC
Authorized Official - Phone:757-618-6311
Mailing Address - Street 1:5741 CLEVELAND ST STE 150
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1777
Mailing Address - Country:US
Mailing Address - Phone:757-422-5502
Mailing Address - Fax:757-455-8055
Practice Address - Street 1:5741 CLEVELAND ST STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1777
Practice Address - Country:US
Practice Address - Phone:757-422-5502
Practice Address - Fax:757-455-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001182636163WL0100X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty