Provider Demographics
NPI:1164452884
Name:CANON, SANDRA CARMEN (DC)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:CARMEN
Last Name:CANON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:CARMEN
Other - Last Name:LITANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:131 E MAIN ST
Mailing Address - Street 2:P.O. BOX 196
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-9377
Mailing Address - Country:US
Mailing Address - Phone:608-655-4164
Mailing Address - Fax:608-655-4386
Practice Address - Street 1:131 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9377
Practice Address - Country:US
Practice Address - Phone:608-655-4164
Practice Address - Fax:608-655-4386
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3185111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38996300Medicaid
WIU53542Medicare UPIN
WI38996300Medicaid