Healthcare Provider Details

I. General information

NPI: 1083439566
Provider Name (Legal Business Name): PROACTIVE WELLNESS GROUP OF PLAINFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12426 S VAN DYKE RD
PLAINFIELD IL
60585-2703
US

IV. Provider business mailing address

12426 S VAN DYKE RD
PLAINFIELD IL
60585-2703
US

V. Phone/Fax

Practice location:
  • Phone: 815-782-6903
  • Fax:
Mailing address:
  • Phone: 815-782-6903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARK J HUMBERT
Title or Position: OWNER
Credential: DC
Phone: 815-782-6903