Provider Demographics
NPI:1144324377
Name:REISS, RYAN ROBERT (DC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:ROBERT
Last Name:REISS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W JACKSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1676
Mailing Address - Country:US
Mailing Address - Phone:618-443-2026
Mailing Address - Fax:618-443-2028
Practice Address - Street 1:202 W JACKSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1676
Practice Address - Country:US
Practice Address - Phone:618-443-2026
Practice Address - Fax:618-443-2028
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010604111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor