Provider Demographics
NPI:1285491951
Name:TIDEWATER SUPERIOR HOME SUPPORT LLC
Entity type:Organization
Organization Name:TIDEWATER SUPERIOR HOME SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-673-4731
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-1483
Mailing Address - Country:US
Mailing Address - Phone:267-673-4731
Mailing Address - Fax:
Practice Address - Street 1:1226 WHITE MARSH RD STE 222
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4055
Practice Address - Country:US
Practice Address - Phone:267-673-4731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care