Provider Demographics
NPI:1295253987
Name:TIDEWATER DIAGNOSTIC CONSULTANTS, LLC
Entity type:Organization
Organization Name:TIDEWATER DIAGNOSTIC CONSULTANTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDIDA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:SINGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-366-1133
Mailing Address - Street 1:524 NORMANDY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-4312
Mailing Address - Country:US
Mailing Address - Phone:757-589-2673
Mailing Address - Fax:757-966-7954
Practice Address - Street 1:5215 COLLEY AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2166
Practice Address - Country:US
Practice Address - Phone:877-366-1133
Practice Address - Fax:757-257-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D2135077291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory