Provider Demographics
NPI:1023362688
Name:CANNONHOMEHEALTHCARE
Entity Type:Organization
Organization Name:CANNONHOMEHEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-200-1832
Mailing Address - Street 1:7108 HOLLYHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-3734
Mailing Address - Country:US
Mailing Address - Phone:704-200-1832
Mailing Address - Fax:704-454-7464
Practice Address - Street 1:7108 HOLLYHOUSE DR
Practice Address - Street 2:7108 HOLLY HOUSE DR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-3734
Practice Address - Country:US
Practice Address - Phone:704-200-1832
Practice Address - Fax:704-454-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies