Provider Demographics
NPI:1104247733
Name:TIDEWATER HOME MODIFIERS LLC
Entity type:Organization
Organization Name:TIDEWATER HOME MODIFIERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTLEY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:COWLING
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-618-4064
Mailing Address - Street 1:206 MARINA CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3402
Mailing Address - Country:US
Mailing Address - Phone:757-618-4064
Mailing Address - Fax:
Practice Address - Street 1:206 MARINA CT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3402
Practice Address - Country:US
Practice Address - Phone:757-618-4064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-28
Last Update Date:2013-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty