1235365503 NPI number — HEADACHE INSTITUTE OF TIDEWATER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235365503 NPI number — HEADACHE INSTITUTE OF TIDEWATER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEADACHE INSTITUTE OF TIDEWATER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235365503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 LYNNHAVEN PKWY
Provider Second Line Business Mailing Address:
SUITE 285
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23452-7332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-368-1891
Provider Business Mailing Address Fax Number:
757-368-4041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 LYNNHAVEN PKWY
Provider Second Line Business Practice Location Address:
SUITE 285
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23452-7332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-368-1891
Provider Business Practice Location Address Fax Number:
757-368-4041
Provider Enumeration Date:
06/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PUGACH
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
757-368-1891

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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