Provider Demographics
NPI:1972613750
Name:BANNON, TIMOTHY S (DC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:S
Last Name:BANNON
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 1:411 E FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7152
Mailing Address - Country:US
Mailing Address - Phone:704-864-7774
Mailing Address - Fax:704-810-8998
Practice Address - Street 1:411 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7152
Practice Address - Country:US
Practice Address - Phone:704-864-7774
Practice Address - Fax:704-810-8998
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001321211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890842VMedicaid
U76374Medicare UPIN
NC890842VMedicaid