Healthcare Provider Details

I. General information

NPI: 1215294822
Provider Name (Legal Business Name): CANNON HOME HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 HOLLYHOUSE DR
CHARLOTTE NC
28215-3734
US

IV. Provider business mailing address

7108 HOLLYHOUSE DR
CHARLOTTE NC
28215-3734
US

V. Phone/Fax

Practice location:
  • Phone: 704-491-9702
  • Fax: 704-454-7464
Mailing address:
  • Phone: 704-491-9702
  • Fax: 704-454-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. GREG J KRYPEL
Title or Position: VP OF OPERATIONS
Credential: MSED
Phone: 704-491-9702