Provider Demographics
NPI:1164837647
Name:CANNON CHIROPRACTIC
Entity Type:Organization
Organization Name:CANNON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:208-557-1880
Mailing Address - Street 1:2052 JENNIE LEE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7047
Mailing Address - Country:US
Mailing Address - Phone:208-557-1880
Mailing Address - Fax:208-874-4273
Practice Address - Street 1:2052 JENNIE LEE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7047
Practice Address - Country:US
Practice Address - Phone:208-557-1880
Practice Address - Fax:208-874-4273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1580261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care