Provider Demographics
NPI:1295858629
Name:ACTIVE HEALTHCARE, LTD
Entity Type:Organization
Organization Name:ACTIVE HEALTHCARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BULYAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-275-3200
Mailing Address - Street 1:5315 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2531
Mailing Address - Country:US
Mailing Address - Phone:773-275-3200
Mailing Address - Fax:773-275-2877
Practice Address - Street 1:5315 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2531
Practice Address - Country:US
Practice Address - Phone:773-275-3200
Practice Address - Fax:773-275-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty