Healthcare Provider Details

I. General information

NPI: 1083249825
Provider Name (Legal Business Name): CHESAPEAKE HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11950 MACCORKLE AVE
CHESAPEAKE WV
25315-1135
US

IV. Provider business mailing address

11950 MACCORKLE AVE
CHESAPEAKE WV
25315-1135
US

V. Phone/Fax

Practice location:
  • Phone: 304-220-2111
  • Fax:
Mailing address:
  • Phone: 304-220-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GENISE LYNN LALOS
Title or Position: CEO
Credential:
Phone: 304-690-3802