Provider Demographics
NPI:1003865981
Name:CANNON, TERRELL RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:TERRELL
Middle Name:RAY
Last Name:CANNON
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 1:6047 SCONCE RD
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OR
Mailing Address - Zip Code:97032-9447
Mailing Address - Country:US
Mailing Address - Phone:503-651-2050
Mailing Address - Fax:
Practice Address - Street 1:530 NW 3RD ST
Practice Address - Street 2:SUITEA
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3646
Practice Address - Country:US
Practice Address - Phone:541-265-8680
Practice Address - Fax:541-265-9595
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR131651Medicare ID - Type Unspecified