Provider Demographics
NPI:1417135716
Name:KEN CASSORLA CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:KEN CASSORLA CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:CASSORLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:831-462-3400
Mailing Address - Street 1:3811 PORTOLA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-5232
Mailing Address - Country:US
Mailing Address - Phone:831-462-3400
Mailing Address - Fax:831-475-1122
Practice Address - Street 1:3811 PORTOLA DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-5232
Practice Address - Country:US
Practice Address - Phone:831-462-3400
Practice Address - Fax:831-475-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13971261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0139710Medicare PIN