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NPI Code Detail

MEDICARE: ACTIVE WELLNESS, LLC

MEDICARE: ACTIVE WELLNESS, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1111NN1001XNutrition Chiropractor24800594IL
2111NP0017XPediatric Chiropractor24800594IL
3171100000XAcupuncturist
4111N00000XChiropractor24800594IL

General Provider Information

NPI Number : 1902162662
Entity Type Code : Organization
Provider Name (Legal Business Name) : ACTIVE WELLNESS, LLC
Provider Business Mailing Address
First Line : 4555 N LINCOLN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60625-2102
Country : US
Telephone Number : 773-328-8153
Fax Number :
Provider Business Practice Location Address
First Line : 4555 N LINCOLN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60625-2102
Country : US
Telephone Number : 773-328-8153
Fax Number :
Authorized Official
Title or Position : GENERAL MANAGER
Name : ANDREW INGLEY
Credential :
Telephone Number : 813-220-9113
Provider Enumeration Date : 04/06/2012
Last Update Date : 02/14/2014

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Directions to “ACTIVE WELLNESS, LLC ” Practice Location

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