Provider Demographics
NPI:1386654929
Name:DEGRADO, RALPH JERRY (DC)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:JERRY
Last Name:DEGRADO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:JERRY
Other - Last Name:DEGRADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:5119 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1625
Mailing Address - Country:US
Mailing Address - Phone:316-686-7558
Mailing Address - Fax:775-703-0118
Practice Address - Street 1:5119 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1625
Practice Address - Country:US
Practice Address - Phone:316-686-7558
Practice Address - Fax:775-703-0118
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-03773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
00738001Medicare PIN