Healthcare Provider Details

I. General information

NPI: 1790279651
Provider Name (Legal Business Name): CHESAPEAKE HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11950 MACCORKLE AVE
CHESAPEAKE WV
25315-1135
US

IV. Provider business mailing address

5054 BENNINGTON DR
CHARLESTON WV
25313-2051
US

V. Phone/Fax

Practice location:
  • Phone: 304-690-3802
  • Fax:
Mailing address:
  • Phone: 304-690-3802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. GENISE L LALOS
Title or Position: OWNER
Credential: MA
Phone: 304-690-3802