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General NPI Number Information
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NPI Number | 1265847545
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Entity Type | Organization
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Legal Business Name | ACTIVE WELLNESS, LLC
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Dates
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Enumeration Date | 06/25/2014
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Last Update Date | 06/25/2014
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Provider Practice Location Address
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Address Line | 4555 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60625-2102
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Country | US
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Telephone | 773-273-6734
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Fax | 773-596-1348
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Provider Business Mailing Address
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Address Line | 118 S CLINTON ST UNIT 100
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City | CHICAGO
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State | IL
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Zip | 60661-3628
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Country | US
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Telephone | 773-598-4387
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Fax | 773-596-1348
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Authorized Official
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Title or Position | MANAGER
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Name | MR. ANDREW INGLEY
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Credential |
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Telephone | 773-273-6734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111NP0017X
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Taxonomy Name | Pediatric Chiropractor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 111NX0800X
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Taxonomy Name | Orthopedic Chiropractor
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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