Provider Demographics
NPI:1316369150
Name:DR. ROBERT DESTEFANO CHIROPRACTIC AND ASSOCIATES LLC
Entity Type:Organization
Organization Name:DR. ROBERT DESTEFANO CHIROPRACTIC AND ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:DESTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-880-8866
Mailing Address - Street 1:75 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8504
Mailing Address - Country:US
Mailing Address - Phone:201-880-8866
Mailing Address - Fax:201-880-8867
Practice Address - Street 1:75 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8504
Practice Address - Country:US
Practice Address - Phone:201-880-8866
Practice Address - Fax:201-880-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00663300111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty