Provider Demographics
NPI:1154780617
Name:ACTIVE LIFE & SPORTS CHIROPRACTIC LLC
Entity type:Organization
Organization Name:ACTIVE LIFE & SPORTS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRYDRYCH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:630-519-6284
Mailing Address - Street 1:929 S MAIN ST
Mailing Address - Street 2:UNIT 107A
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-519-6284
Mailing Address - Fax:866-443-0749
Practice Address - Street 1:929 S MAIN ST
Practice Address - Street 2:UNIT 107A
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3325
Practice Address - Country:US
Practice Address - Phone:630-519-6284
Practice Address - Fax:866-443-0749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00055OtherMEDICARE PTAN