Provider Demographics
NPI:1710989389
Name:DESTEFANO, CARL J (DC)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:J
Last Name:DESTEFANO
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 1:65 N RIVER LN
Mailing Address - Street 2:BLDG C # 207
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4519
Mailing Address - Country:US
Mailing Address - Phone:630-208-7760
Mailing Address - Fax:630-208-7672
Practice Address - Street 1:65 N RIVER LN
Practice Address - Street 2:BLDG C # 207
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4519
Practice Address - Country:US
Practice Address - Phone:630-208-7760
Practice Address - Fax:630-208-7672
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor