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General NPI Number Information
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NPI Number | 1164837647
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Entity Type | Organization
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Legal Business Name | CANNON CHIROPRACTIC
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Dates
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Enumeration Date | 06/24/2014
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Last Update Date | 06/24/2014
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Provider Practice Location Address
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Address Line | 2052 JENNIE LEE DR SUITE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7047
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Country | US
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Telephone | 208-557-1880
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Fax | 208-874-4273
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Provider Business Mailing Address
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Address Line | 2052 JENNIE LEE DR SUITE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7047
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Country | US
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Telephone | 208-557-1880
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Fax | 208-874-4273
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Authorized Official
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Title or Position | CHIROPRACTIC PHYSICIAN, OWNER
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Name | DR. TIMOTHY W CANNON
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Credential | D.C., M.S.
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Telephone | 208-557-1880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | CHIA-1580
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License Number State | ID
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