Provider Demographics
NPI:1588416762
Name:DESTEPHANO, NIKOLAS (DC)
Entity type:Individual
Prefix:
First Name:NIKOLAS
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 HIGHWAY 12 STE 101
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8308
Mailing Address - Country:US
Mailing Address - Phone:815-675-0675
Mailing Address - Fax:
Practice Address - Street 1:2100 N US HIGHWAY 12 STE 101
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-8308
Practice Address - Country:US
Practice Address - Phone:815-675-0675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.014140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor