Provider Demographics
NPI:1053814814
Name:CHICAGO FUNCTIONAL NEUROLOGY GROUP, LTD.
Entity Type:Organization
Organization Name:CHICAGO FUNCTIONAL NEUROLOGY GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DESTEPHANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DACBN
Authorized Official - Phone:312-767-3500
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:815-675-9836
Practice Address - Street 1:30 S MICHIGAN AVE STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-3225
Practice Address - Country:US
Practice Address - Phone:312-767-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007206111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty