Provider Demographics
NPI:1205915188
Name:TIDEWATER HOSPICE, INC.
Entity type:Organization
Organization Name:TIDEWATER HOSPICE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-331-6271
Mailing Address - Street 1:500 FAULCONER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-5089
Mailing Address - Country:US
Mailing Address - Phone:434-977-9711
Mailing Address - Fax:434-235-4142
Practice Address - Street 1:10 BUCKINGHAM PLANTATION DR STE A
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6503
Practice Address - Country:US
Practice Address - Phone:843-757-9388
Practice Address - Fax:843-757-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based