MEDICARE: PRO-ACTIVE CARE PHYSICAL MEDICINE SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038010690	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IL7812	OTHER	IL	MEDICARE PTAN

General Provider Information

NPI Number	:	1356600712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO-ACTIVE CARE PHYSICAL MEDICINE SC

Provider Business Mailing Address
First Line	:	2609 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-6895
Country	:	US
Telephone Number	:	773-279-9344
Fax Number	:	773-279-9345

Provider Business Practice Location Address
First Line	:	2609 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-6895
Country	:	US
Telephone Number	:	773-279-9344
Fax Number	:	773-279-9345

Authorized Official
Title or Position	:	P
Name	:	DR. RAE BOUVIN
Credential	:	D.C.
Telephone Number	:	773-279-9344

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	02/09/2016

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