Healthcare Provider Details

I. General information

NPI: 1427483791
Provider Name (Legal Business Name): ACTIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 N SOUTHPORT AVE
CHICAGO IL
60657-1436
US

IV. Provider business mailing address

4555 N LINCOLN AVE
CHICAGO IL
60625-2102
US

V. Phone/Fax

Practice location:
  • Phone: 773-598-4387
  • Fax:
Mailing address:
  • Phone: 773-328-8153
  • Fax:

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 Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

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