Provider Demographics
NPI:1649565664
Name:DR. RICKY SAM CAVALLARO FAMILY CHIROPRACTOR PLLC
Entity type:Organization
Organization Name:DR. RICKY SAM CAVALLARO FAMILY CHIROPRACTOR PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-487-5200
Mailing Address - Street 1:100 OSCEOLA PL.
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1242
Mailing Address - Country:US
Mailing Address - Phone:315-487-5200
Mailing Address - Fax:315-487-1110
Practice Address - Street 1:100 OSCEOLA PL.
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1242
Practice Address - Country:US
Practice Address - Phone:315-487-5200
Practice Address - Fax:315-487-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52539BMedicare PIN
U11661Medicare UPIN