Provider Demographics
NPI:1477582302
Name:ACTIVE BODY CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:ACTIVE BODY CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT / COO
Authorized Official - Prefix:DR
Authorized Official - First Name:DYLAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DRYNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-922-9868
Mailing Address - Street 1:1600 S INDIANA AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4732
Mailing Address - Country:US
Mailing Address - Phone:312-922-9868
Mailing Address - Fax:312-922-9869
Practice Address - Street 1:1600 S INDIANA AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4732
Practice Address - Country:US
Practice Address - Phone:312-922-9868
Practice Address - Fax:312-922-9869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-008054111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632378OtherBLUE CROSS BLUE SHIELD ID
203927Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
IL=========Medicare UPIN