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Organization
PRO-ACTIVE CARE PHYSICAL MEDICINE SC
Active
Organization
PRO-ACTIVE CARE PHYSICAL MEDICINE SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RAE BOUVIN D.C. (P)
(773) 279-9344
Entity
Organization
Contact information
Practice address
2609 W LAWRENCE AVE, CHICAGO, IL 60625-6895
(773) 279-9344
(773) 279-9345
Mailing address
2609 W LAWRENCE AVE, CHICAGO, IL 60625-6895
(773) 279-9344
(773) 279-9345
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
038010690
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL7812
MEDICARE PTAN
IL
Enumeration date
05/04/2012
Last updated
02/09/2016
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