Provider Demographics
NPI:1215025341
Name:IRELAND, REX ANTHONY (DC)
Entity type:Individual
Prefix:MR
First Name:REX
Middle Name:ANTHONY
Last Name:IRELAND
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 1:5940 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1677
Mailing Address - Country:US
Mailing Address - Phone:260-436-8899
Mailing Address - Fax:260-436-1522
Practice Address - Street 1:5940 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1677
Practice Address - Country:US
Practice Address - Phone:260-436-8899
Practice Address - Fax:260-436-1522
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001738A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor