Provider Demographics
NPI:1033736822
Name:CANNON RIDGE DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:CANNON RIDGE DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-617-7974
Mailing Address - Street 1:77 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:GRANTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28529-9457
Mailing Address - Country:US
Mailing Address - Phone:252-617-7974
Mailing Address - Fax:
Practice Address - Street 1:11560 NC 55 HWY STE 7
Practice Address - Street 2:
Practice Address - City:GRANTSBORO
Practice Address - State:NC
Practice Address - Zip Code:28529-9447
Practice Address - Country:US
Practice Address - Phone:252-242-0088
Practice Address - Fax:252-631-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty