MEDICARE: NORTH SHORE PRO-ACTIVE HEALTH LLC

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	038-010764	IL

General Provider Information

NPI Number	:	1780812784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE PRO-ACTIVE HEALTH LLC

Provider Business Mailing Address
First Line	:	112 W LAKE ST
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1812
Country	:	US
Telephone Number	:	847-362-4476
Fax Number	:	847-367-5339

Provider Business Practice Location Address
First Line	:	112 W LAKE ST
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1812
Country	:	US
Telephone Number	:	847-362-4476
Fax Number	:	847-367-5339

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. JORDAN L LEASURE
Credential	:	DC
Telephone Number	:	847-362-4476

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	03/03/2015

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