Provider Demographics
NPI:1518295740
Name:CANNON, ERIC JUSTIN
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JUSTIN
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7246
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-7246
Mailing Address - Country:US
Mailing Address - Phone:843-453-2891
Mailing Address - Fax:843-662-1995
Practice Address - Street 1:632 KING AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4331
Practice Address - Country:US
Practice Address - Phone:843-453-2891
Practice Address - Fax:843-662-1995
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC343900000X343900000X
SC347C00000X347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPCS/ORS 8156OtherORS- OFFICE OF REGULATORY STAFF