Provider Demographics
NPI:1992058747
Name:SURPRENANT, CRYSTAL REGINA (DC)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:REGINA
Last Name:SURPRENANT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 N IL ROUTE 83
Mailing Address - Street 2:STE A
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7932
Mailing Address - Country:US
Mailing Address - Phone:847-548-4800
Mailing Address - Fax:847-548-4804
Practice Address - Street 1:1227 N IL ROUTE 83
Practice Address - Street 2:STE A
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7932
Practice Address - Country:US
Practice Address - Phone:847-548-4800
Practice Address - Fax:847-548-4804
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012253111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor