Provider Demographics
NPI:1205877867
Name:VASSALLO, SAM (DC)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:VASSALLO
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 1:24304 NYS RTE 37
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5870
Mailing Address - Country:US
Mailing Address - Phone:315-785-9588
Mailing Address - Fax:315-786-3099
Practice Address - Street 1:24304 NYS RTE 37
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5870
Practice Address - Country:US
Practice Address - Phone:315-785-9588
Practice Address - Fax:315-786-3099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor