Provider Demographics
NPI:1477823938
Name:FULL LIFE REJUVENATION
Entity Type:Organization
Organization Name:FULL LIFE REJUVENATION
Other - Org Name:NORTH SHORE HEALTH SOLUTIONS LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:JACOBS
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-736-9555
Mailing Address - Street 1:1446 TECHNY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5447
Mailing Address - Country:US
Mailing Address - Phone:847-736-9555
Mailing Address - Fax:847-386-6270
Practice Address - Street 1:1446 TECHNY RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5447
Practice Address - Country:US
Practice Address - Phone:847-736-9555
Practice Address - Fax:847-386-6270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011644111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty