Provider Demographics
NPI:1598301301
Name:GREEN, ILAN (DC)
Entity Type:Individual
Prefix:DR
First Name:ILAN
Middle Name:
Last Name:GREEN
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 1:827 W LANCASTER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3436
Mailing Address - Country:US
Mailing Address - Phone:610-808-9960
Mailing Address - Fax:610-808-9960
Practice Address - Street 1:827 W LANCASTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3436
Practice Address - Country:US
Practice Address - Phone:610-808-9960
Practice Address - Fax:610-808-9960
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61013340111N00000X
PADC011631111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor