Healthcare Provider Details

I. General information

NPI: 1316369150
Provider Name (Legal Business Name): DR. ROBERT DESTEFANO CHIROPRACTIC AND ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SUMMIT AVE
HACKENSACK NJ
07601-8504
US

IV. Provider business mailing address

75 SUMMIT AVE
HACKENSACK NJ
07601-8504
US

V. Phone/Fax

Practice location:
  • Phone: 201-880-8866
  • Fax: 201-880-8867
Mailing address:
  • Phone: 201-880-8866
  • Fax: 201-880-8867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00663300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00663300
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT L DESTEFANO
Title or Position: D.C.
Credential: D.C.
Phone: 201-880-8866