=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184557803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANNON COTTAGE FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2026
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15256 SUNCHASER ST
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92394-7580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-265-6081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 599 N ARROWHEAD AVE UNIT 6
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92401-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-265-6081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SHELETA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-265-6081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 177F00000X
-----------------------------------------------------
Taxonomy Name | Lodging Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------