Provider Demographics
NPI:1134474414
Name:PROACTIVE SPORT & SPINE, SC
Entity Type:Organization
Organization Name:PROACTIVE SPORT & SPINE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-997-3380
Mailing Address - Street 1:3340 DUNDEE RD
Mailing Address - Street 2:SUITE 2C4
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2324
Mailing Address - Country:US
Mailing Address - Phone:224-235-4651
Mailing Address - Fax:224-235-4654
Practice Address - Street 1:3340 DUNDEE RD
Practice Address - Street 2:SUITE 2C4
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2324
Practice Address - Country:US
Practice Address - Phone:224-235-4651
Practice Address - Fax:224-235-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011182111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty