Basic Information
| Provider Information | |||||||||
| NPI: | 1518424167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVATE HEALTHCARE - UNITE HERE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 N DAMEN AVE UNIT F | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606473286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736973144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2952 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921023241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197984613 | ||||||||
| FaxNumber: | 6197984614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2019 | ||||||||
| LastUpdateDate: | 03/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | GEIHSLER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
| AuthorizedOfficialTelephone: | 7736973144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.