Provider Demographics
NPI:1225629215
Name:ACTIVATE BODY POTENTIAL, INC.
Entity Type:Organization
Organization Name:ACTIVATE BODY POTENTIAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SUPIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-562-7814
Mailing Address - Street 1:2010 CLIPPER PARK RD STE 115
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1439
Mailing Address - Country:US
Mailing Address - Phone:410-235-5220
Mailing Address - Fax:
Practice Address - Street 1:2010 CLIPPER PARK RD STE 115
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1439
Practice Address - Country:US
Practice Address - Phone:410-235-5220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty