Provider Demographics
NPI:1275213902
Name:PROACTIVE WELLNESS GROUP
Entity Type:Organization
Organization Name:PROACTIVE WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPACCAPANICCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-725-8660
Mailing Address - Street 1:805 W JEFFERSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-7379
Mailing Address - Country:US
Mailing Address - Phone:815-725-8660
Mailing Address - Fax:
Practice Address - Street 1:805 W JEFFERSON ST STE A
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-7379
Practice Address - Country:US
Practice Address - Phone:815-725-8660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty