Provider Demographics
NPI:1144342973
Name:PRO-ACTIVE WELLNESS AND INJURY CENTRE
Entity type:Organization
Organization Name:PRO-ACTIVE WELLNESS AND INJURY CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-431-2010
Mailing Address - Street 1:1207 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-6028
Mailing Address - Country:US
Mailing Address - Phone:217-431-2010
Mailing Address - Fax:217-431-2011
Practice Address - Street 1:1207 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-6028
Practice Address - Country:US
Practice Address - Phone:217-431-2010
Practice Address - Fax:217-431-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004185111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL007115OtherHEALTH ALLIANCE
IN350044571OtherRAILROAD MEDICARE
IL9282010OtherBLUE CROSS BLUE SHIELD
IL679860Medicare ID - Type Unspecified
IN350044571OtherRAILROAD MEDICARE