Provider Demographics
NPI:1619129186
Name:GANNON CHIROPRACTIC CENTER, P.C.
Entity Type:Organization
Organization Name:GANNON CHIROPRACTIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-424-9220
Mailing Address - Street 1:2 SPLIT ROCK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1244
Mailing Address - Country:US
Mailing Address - Phone:856-424-9220
Mailing Address - Fax:856-424-5319
Practice Address - Street 1:2 SPLIT ROCK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1244
Practice Address - Country:US
Practice Address - Phone:856-424-9220
Practice Address - Fax:856-424-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00264900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
180784Medicare PIN