Provider Demographics
NPI:1790279651
Name:CHESAPEAKE HEALTHCARE CENTER
Entity Type:Organization
Organization Name:CHESAPEAKE HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GENISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LALOS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-690-3802
Mailing Address - Street 1:5054 BENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25313-2051
Mailing Address - Country:US
Mailing Address - Phone:304-690-3802
Mailing Address - Fax:
Practice Address - Street 1:11950 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:WV
Practice Address - Zip Code:25315-1135
Practice Address - Country:US
Practice Address - Phone:304-690-3802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center