Provider Demographics
NPI:1194878561
Name:CASSORLA, KEN LOUIS (D,C)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:LOUIS
Last Name:CASSORLA
Suffix:
Gender:M
Credentials:D,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 WILLOW HTS
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-9592
Mailing Address - Country:US
Mailing Address - Phone:831-684-1688
Mailing Address - Fax:831-684-9331
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
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13971111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC139710Medicare ID - Type Unspecified