Provider Demographics
NPI:1750469995
Name:HANNON, CLIVE BRIAN (DC,)
Entity Type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:BRIAN
Last Name:HANNON
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 1:16808 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-7922
Mailing Address - Country:US
Mailing Address - Phone:760-949-0996
Mailing Address - Fax:760-949-0777
Practice Address - Street 1:16808 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-7922
Practice Address - Country:US
Practice Address - Phone:760-949-0996
Practice Address - Fax:760-949-0777
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0148451OtherBLUE SHIELD
CADC0148451Medicare ID - Type Unspecified
CADC0148451OtherBLUE SHIELD