Provider Demographics
NPI:1932565074
Name:RAYNER, IVAN III (DC)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:RAYNER
Suffix:III
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 1:111 N WABASH AVE STE 1414
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3070
Mailing Address - Country:US
Mailing Address - Phone:312-819-4239
Mailing Address - Fax:
Practice Address - Street 1:111 N WABASH AVE STE 1414
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3070
Practice Address - Country:US
Practice Address - Phone:312-819-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2018-12-20
Deactivation Date:2018-12-10
Deactivation Code:
Reactivation Date:2018-12-19
Provider Licenses
StateLicense IDTaxonomies
IL277.016927225700000X
IL038.013280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist