Provider Demographics
NPI:1124471859
Name:PROACTIVE CHIROPRACTIC GROUP OF PLAINFIELD INC
Entity type:Organization
Organization Name:PROACTIVE CHIROPRACTIC GROUP OF PLAINFIELD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-351-2722
Mailing Address - Street 1:12426 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12426 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2700
Practice Address - Country:US
Practice Address - Phone:815-351-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty