Provider Demographics
NPI:1659688406
Name:ATIVA HEALTH CENTER LLC
Entity Type:Organization
Organization Name:ATIVA HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:YULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIKHOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-536-0219
Mailing Address - Street 1:3510 E LANCASTER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-2555
Mailing Address - Country:US
Mailing Address - Phone:817-536-0219
Mailing Address - Fax:817-536-0311
Practice Address - Street 1:3510 E LANCASTER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-2555
Practice Address - Country:US
Practice Address - Phone:817-536-0219
Practice Address - Fax:817-536-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty