Healthcare Provider Details

I. General information

NPI: 1790791911
Provider Name (Legal Business Name): GREGORY E CANNON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8002 MENAUL BLVD NE
ALBUQUERQUE NM
87110-4608
US

IV. Provider business mailing address

8002 MENAUL BLVD NE
ALBUQUERQUE NM
87110-4608
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-7646
  • Fax: 505-294-7646
Mailing address:
  • Phone: 505-294-7646
  • Fax: 505-294-7646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1383
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: