Provider Demographics
NPI:1235721879
Name:LORENA CANNON LLC
Entity Type:Organization
Organization Name:LORENA CANNON LLC
Other - Org Name:PEACHTREE MEDICAL CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:208-351-5458
Mailing Address - Street 1:893 E 9400 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3671
Mailing Address - Country:US
Mailing Address - Phone:385-335-7862
Mailing Address - Fax:
Practice Address - Street 1:893 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3671
Practice Address - Country:US
Practice Address - Phone:385-335-7862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty