Provider Demographics
NPI:1245659127
Name:TIDEWATER HOME HEALTH, PA
Entity type:Organization
Organization Name:TIDEWATER HOME HEALTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-600-0842
Mailing Address - Street 1:215 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3653
Mailing Address - Country:US
Mailing Address - Phone:803-753-7017
Mailing Address - Fax:803-739-7079
Practice Address - Street 1:215 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3653
Practice Address - Country:US
Practice Address - Phone:803-753-7017
Practice Address - Fax:803-739-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC460342251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health