Provider Demographics
NPI:1497171177
Name:IRIE, ILAN
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:IRIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CHICOPEE DR
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2639
Mailing Address - Country:US
Mailing Address - Phone:404-374-1924
Mailing Address - Fax:
Practice Address - Street 1:4646 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6308
Practice Address - Country:US
Practice Address - Phone:770-676-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist