Healthcare Provider Details

I. General information

NPI: 1902162662
Provider Name (Legal Business Name): ACTIVE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 N LINCOLN AVE
CHICAGO IL
60625-2102
US

IV. Provider business mailing address

4555 N LINCOLN AVE
CHICAGO IL
60625-2102
US

V. Phone/Fax

Practice location:
  • Phone: 773-328-8153
  • Fax:
Mailing address:
  • Phone: 773-328-8153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number24800594
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number24800594
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number24800594
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW INGLEY
Title or Position: GENERAL MANAGER
Credential:
Phone: 813-220-9113