Provider Demographics
NPI:1942066279
Name:HENDRICKS, CASEY RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:RYAN
Last Name:HENDRICKS
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 1:72 N BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1801
Mailing Address - Country:US
Mailing Address - Phone:907-617-2545
Mailing Address - Fax:
Practice Address - Street 1:1399 S WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4300
Practice Address - Country:US
Practice Address - Phone:408-261-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36907111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician