Provider Demographics
NPI:1134002439
Name:TIDELANDS HEALTH
Entity type:Organization
Organization Name:TIDELANDS HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-327-8894
Mailing Address - Street 1:6723 GENESIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:631-327-8894
Mailing Address - Fax:631-327-8894
Practice Address - Street 1:11916 HIGHWAY 707 STE D
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9610
Practice Address - Country:US
Practice Address - Phone:843-652-8450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care