Provider Demographics
NPI:1972750420
Name:TIDEWATER WEIGHT LOSS AND WELLNESS CENTERS,INC.
Entity Type:Organization
Organization Name:TIDEWATER WEIGHT LOSS AND WELLNESS CENTERS,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MURRAY
Authorized Official - Last Name:CHALENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-480-5673
Mailing Address - Street 1:2468 E LITTLE CREEK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-3231
Mailing Address - Country:US
Mailing Address - Phone:757-480-5673
Mailing Address - Fax:757-480-2333
Practice Address - Street 1:2468 E LITTLE CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3231
Practice Address - Country:US
Practice Address - Phone:757-480-5673
Practice Address - Fax:757-480-2333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:0101231458
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231458261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center