Healthcare Provider Details

I. General information

NPI: 1619095866
Provider Name (Legal Business Name): ACTIVE FAMILY CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 MERCHANT DR
ALGONQUIN IL
60102-5917
US

IV. Provider business mailing address

1455 MERCHANT DR
ALGONQUIN IL
60102-5917
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-4545
  • Fax:
Mailing address:
  • Phone: 847-854-4545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CLIFTON SAMUEL BRERETON
Title or Position: PRESIDENT
Credential: DC
Phone: 847-854-4545