Provider Demographics
NPI:1811447725
Name:LOOSE CANNON SOCIAL WORK, LLC.
Entity type:Organization
Organization Name:LOOSE CANNON SOCIAL WORK, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-652-4437
Mailing Address - Street 1:2298 E 200 S
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1603
Mailing Address - Country:US
Mailing Address - Phone:801-652-4437
Mailing Address - Fax:
Practice Address - Street 1:2298 E 200 S
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-1603
Practice Address - Country:US
Practice Address - Phone:801-652-4437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8202232-3501302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization