Provider Demographics
NPI:1891885851
Name:BANNON CLINIC OF CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:BANNON CLINIC OF CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-864-7774
Mailing Address - Street 1:1002 S NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3801
Mailing Address - Country:US
Mailing Address - Phone:704-864-7774
Mailing Address - Fax:704-810-8998
Practice Address - Street 1:1002 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3801
Practice Address - Country:US
Practice Address - Phone:704-864-7774
Practice Address - Fax:704-810-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890842VMedicaid
NC890842VMedicaid
NCU76374Medicare UPIN