# WESTERN TIDEWATER FREE CLINIC INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295219210
- **Authorized official:** MR. CHESTER MARVIN HART (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (757) 923-1060

## Contact information

- **Practice address:** 2019 MEADE PKWY, SUFFOLK, VA 23434-4259
- **Practice address phone:** (757) 923-1060
- **Practice address fax:** (757) 923-1068
- **Mailing address:** 2019 MEADE PKWY, SUFFOLK, VA 23434-4259
- **Mailing address phone:** (757) 923-1060
- **Mailing address fax:** (757) 923-1068

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 09/17/2018
- **Last updated:** 09/17/2018