Provider Demographics
NPI:1043557309
Name:CANNON, CHARLES KELLY (LAC, MACOM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KELLY
Last Name:CANNON
Suffix:
Gender:M
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:MOSIER
Mailing Address - State:OR
Mailing Address - Zip Code:97040-0312
Mailing Address - Country:US
Mailing Address - Phone:541-386-8767
Mailing Address - Fax:
Practice Address - Street 1:302 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:MOSIER
Practice Address - State:OR
Practice Address - Zip Code:97040-1500
Practice Address - Country:US
Practice Address - Phone:541-386-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC159892171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist