Healthcare Provider Details

I. General information

NPI: 1154792802
Provider Name (Legal Business Name): ACTIVE HEALTH & RESTORATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E SAINT CHARLES RD SUITE 107
CAROL STREAM IL
60188-3083
US

IV. Provider business mailing address

640 E SAINT CHARLES RD SUITE 107
CAROL STREAM IL
60188-3083
US

V. Phone/Fax

Practice location:
  • Phone: 630-923-5049
  • Fax:
Mailing address:
  • Phone: 630-923-5049
  • Fax: 630-344-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038.012819
License Number StateIL

VIII. Authorized Official

Name: DR. ALEXANDER EARL
Title or Position: PRESIDENT, CLINIC DIRECTOR
Credential: D.C.
Phone: 630-923-5049