Healthcare Provider Details

I. General information

NPI: 1134572779
Provider Name (Legal Business Name): YOUNG CANNON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 NE 123RD ST
NORTH MIAMI FL
33181-2902
US

IV. Provider business mailing address

300 SW 97TH TER
PEMBROKE PINES FL
33025-1074
US

V. Phone/Fax

Practice location:
  • Phone: 305-967-8976
  • Fax:
Mailing address:
  • Phone: 954-882-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60752
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: