Healthcare Provider Details

I. General information

NPI: 1265847545
Provider Name (Legal Business Name): ACTIVE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
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

118 S CLINTON ST UNIT 100
CHICAGO IL
60661-3628
US

V. Phone/Fax

Practice location:
  • Phone: 773-273-6734
  • Fax: 773-596-1348
Mailing address:
  • Phone: 773-598-4387
  • Fax: 773-596-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW INGLEY
Title or Position: MANAGER
Credential:
Phone: 773-273-6734