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General NPI Number Information
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NPI Number | 1477582302
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Entity Type | Organization
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Legal Business Name | ACTIVE BODY CHIROPRACTIC LTD
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Dates
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Enumeration Date | 07/02/2006
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Last Update Date | 10/25/2012
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Provider Practice Location Address
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Address Line | 1600 S INDIANA AVE SUITE 2
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City | CHICAGO
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State | IL
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Zip | 60616-4732
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Country | US
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Telephone | 312-922-9868
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Fax | 312-922-9869
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Provider Business Mailing Address
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Address Line | 1600 S INDIANA AVE SUITE 2
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City | CHICAGO
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State | IL
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Zip | 60616-4732
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Country | US
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Telephone | 312-922-9868
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Fax | 312-922-9869
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Authorized Official
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Title or Position | VICE PRESIDENT / COO
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Name | DR. DYLAN P DRYNAN
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Credential | DC
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Telephone | 312-922-9868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 060-008054
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License Number State | IL
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