Provider Demographics
NPI:1255880308
Name:CORNELL, SAMUEL ROY (DC, ATC)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROY
Last Name:CORNELL
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 FELDSPAR WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3518
Mailing Address - Country:US
Mailing Address - Phone:949-338-3880
Mailing Address - Fax:
Practice Address - Street 1:24002 VIA FABRICANTE STE 501
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3934
Practice Address - Country:US
Practice Address - Phone:949-454-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36279111N00000X
AZ15472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer