Provider Demographics
NPI:1922633395
Name:PROACTIVE CHIROPRACTIC & LASER CENTER, LLC
Entity Type:Organization
Organization Name:PROACTIVE CHIROPRACTIC & LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:KURT
Authorized Official - Last Name:FRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-757-5463
Mailing Address - Street 1:2535 BETHANY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3126
Mailing Address - Country:US
Mailing Address - Phone:815-517-0826
Mailing Address - Fax:
Practice Address - Street 1:2535 BETHANY RD STE 100
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3126
Practice Address - Country:US
Practice Address - Phone:815-517-0826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty