Provider Demographics
NPI:1275945701
Name:CANNON CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CANNON CHIROPRACTIC LLC
Other - Org Name:STEVENS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-755-7654
Mailing Address - Street 1:1635 N 200 E
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1913
Mailing Address - Country:US
Mailing Address - Phone:435-755-7654
Mailing Address - Fax:435-753-7654
Practice Address - Street 1:1635 N 200 E
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1913
Practice Address - Country:US
Practice Address - Phone:435-755-7654
Practice Address - Fax:435-753-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7875588-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty