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General NPI Number Information
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NPI Number | 1053814814
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Entity Type | Organization
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Legal Business Name | CHICAGO FUNCTIONAL NEUROLOGY GROUP, LTD.
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Dates
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Enumeration Date | 03/17/2018
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 30 S MICHIGAN AVE STE 302
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City | CHICAGO
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State | IL
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Zip | 60603-3225
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Country | US
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Telephone | 312-767-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 N US HIGHWAY 12 STE 101
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City | SPRING GROVE
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State | IL
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Zip | 60081-8308
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Country | US
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Telephone | 815-675-0675
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Fax | 815-675-9836
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Authorized Official
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Title or Position | OWNER/CHIROPRACTIC NEUROLOGIST
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Name | DR. RALPH P DESTEPHANO
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Credential | DC, DACBN
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Telephone | 312-767-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038007206
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License Number State | IL
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