Provider Demographics
NPI:1700085412
Name:ACTIVA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:ACTIVA MEDICAL CENTER, INC.
Other - Org Name:CONSTANCE NOEL, D.O., INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:650-400-9887
Mailing Address - Street 1:3130 ALPINE RD STE 288-211
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7549
Mailing Address - Country:US
Mailing Address - Phone:650-400-9887
Mailing Address - Fax:
Practice Address - Street 1:1479 YGNACIO VALLEY RD STE 207
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2945
Practice Address - Country:US
Practice Address - Phone:925-946-1098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty