Healthcare Provider Details

I. General information

NPI: 1396657532
Provider Name (Legal Business Name): CAMERON CARLON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 NOREASTER DR
CABINS WV
26855-1104
US

IV. Provider business mailing address

95 NOREASTER DR
CABINS WV
26855-1104
US

V. Phone/Fax

Practice location:
  • Phone: 681-410-4764
  • Fax:
Mailing address:
  • Phone: 681-410-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: