Healthcare Provider Details

I. General information

NPI: 1508779059
Provider Name (Legal Business Name): OLIVER D CANNON JR. 22 YEARS PROF EXPERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14050 KYLE CANTON RD
LAS VEGAS NV
89166
US

IV. Provider business mailing address

14050 KYLE CANTON RD
LAS VEGAS NV
89166
US

V. Phone/Fax

Practice location:
  • Phone: 702-301-5705
  • Fax: 702-395-5800
Mailing address:
  • Phone: 702-301-5705
  • Fax: 702-395-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberNV20201957379
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: