Provider Demographics
NPI:1932244423
Name:ACTIVE LIFE INSTITUTE
Entity Type:Organization
Organization Name:ACTIVE LIFE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSTITUTE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:PRATOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:630-717-8575
Mailing Address - Street 1:304 E OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3159
Mailing Address - Country:US
Mailing Address - Phone:630-717-8575
Mailing Address - Fax:630-717-8573
Practice Address - Street 1:304 E OGDEN AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3159
Practice Address - Country:US
Practice Address - Phone:630-717-8575
Practice Address - Fax:630-717-8573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB0886OtherRAILROAD #
IL02232434OtherBCBS
IL7268512OtherMEDICARE MANAGE CARE #
ILP00086076OtherUPIN RAILROAD MEDICARE
IL02232434OtherBCBS
ILDB0886OtherRAILROAD #
IL02232434OtherBCBS
IL=========OtherTAX IDENTIFIER