MEDICARE: ACTIVE WELLNESS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	111NN1001X	Nutrition Chiropractor
2	111NP0017X	Pediatric Chiropractor
3	111NS0005X	Sports Physician Chiropractor
4	171100000X	Acupuncturist
5	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1427483791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE WELLNESS LLC

Provider Business Mailing Address
First Line	:	4555 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2102
Country	:	US
Telephone Number	:	773-328-8153
Fax Number	:

Provider Business Practice Location Address
First Line	:	3514 N SOUTHPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1436
Country	:	US
Telephone Number	:	773-598-4387
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ANDREW INGLEY
Credential	:
Telephone Number	:	813-220-9113

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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Directions to “ACTIVE WELLNESS LLC ” Practice Location

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