Provider Demographics
NPI:1578922878
Name:ACTIVATE HEALTHCARE - TEAMSTERS 175 & 505 CLINIC
Entity Type:Organization
Organization Name:ACTIVATE HEALTHCARE - TEAMSTERS 175 & 505 CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEIHSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-697-3144
Mailing Address - Street 1:2010 N DAMEN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3284
Mailing Address - Country:US
Mailing Address - Phone:773-697-3144
Mailing Address - Fax:
Practice Address - Street 1:428 DIVISION ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1469
Practice Address - Country:US
Practice Address - Phone:304-768-0321
Practice Address - Fax:304-768-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care