Provider Demographics
NPI:1053429670
Name:DESTEPHANO, RALPH (DC)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:DESTEPHANO
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 1:2100 N US HWY 12
Mailing Address - Street 2:SUITE101
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081
Mailing Address - Country:US
Mailing Address - Phone:815-675-0675
Mailing Address - Fax:815-675-9836
Practice Address - Street 1:2100 N US HWY 12
Practice Address - Street 2:SUITE 101
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081
Practice Address - Country:US
Practice Address - Phone:815-675-0675
Practice Address - Fax:815-675-9836
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007206111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
C73740Medicare UPIN
ILK10590Medicare UPIN