Provider Demographics
NPI:1275674145
Name:HANNAM, DWAYNE ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:ROBERT
Last Name:HANNAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W GROVE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-1462
Mailing Address - Country:US
Mailing Address - Phone:508-947-6455
Mailing Address - Fax:
Practice Address - Street 1:205 W GROVE ST
Practice Address - Street 2:SUITE D
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346-1462
Practice Address - Country:US
Practice Address - Phone:508-947-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY49142Medicare ID - Type Unspecified