Provider Demographics
NPI:1770755134
Name:CANNON CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:CANNON CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:D
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:901-840-2234
Mailing Address - Street 1:81 ATOKA MCLAUGHLIN
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004
Mailing Address - Country:US
Mailing Address - Phone:901-840-2234
Mailing Address - Fax:901-840-2237
Practice Address - Street 1:81 ATOKA MCLAUGHLIN
Practice Address - Street 2:SUITE B
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004
Practice Address - Country:US
Practice Address - Phone:901-840-2234
Practice Address - Fax:901-840-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1770755134OtherFACILITY NPI NUMBER
TNU95044Medicare UPIN
TN36725892Medicare PIN