Provider Demographics
NPI:1659476752
Name:TIDEWATER EYE CENTERS PC
Entity type:Organization
Organization Name:TIDEWATER EYE CENTERS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN / MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ASTON
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:757-397-7858
Mailing Address - Street 1:3603 COUNTY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3103
Mailing Address - Country:US
Mailing Address - Phone:757-397-2020
Mailing Address - Fax:757-673-6832
Practice Address - Street 1:3601 COUNTY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3103
Practice Address - Country:US
Practice Address - Phone:757-397-7858
Practice Address - Fax:757-673-6832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier