Healthcare Provider Details

I. General information

NPI: 1083782155
Provider Name (Legal Business Name): ACTIVECARE NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 HALF DAY RD SUITE 333
BANNOCKBURN IL
60015-1217
US

IV. Provider business mailing address

2275 HALF DAY RD SUITE 333
BANNOCKBURN IL
60015-1217
US

V. Phone/Fax

Practice location:
  • Phone: 847-267-9400
  • Fax: 847-267-9411
Mailing address:
  • Phone: 847-267-9400
  • Fax: 847-267-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MS. JUDI ANN GRUPP
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 847-267-9400