Provider Demographics
NPI:1205345444
Name:TIDEWATER PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:TIDEWATER PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:154 E LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-2503
Practice Address - Country:US
Practice Address - Phone:757-797-0210
Practice Address - Fax:757-453-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN