1639123565 NPI number — DR. NICHOLAS CANNON D.C.

Table of content: DR. NICHOLAS CANNON D.C. (NPI 1639123565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639123565 NPI number — DR. NICHOLAS CANNON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNON
Provider First Name:
NICHOLAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639123565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 MAPLE ST STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEBURY
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05753-1168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-458-0488
Provider Business Mailing Address Fax Number:
802-458-0489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 MAPLE ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05753-1168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-458-0488
Provider Business Practice Location Address Fax Number:
802-458-0489
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  006-0001191 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010529023 . This is a "MEDNET" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: AA57163 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 010529023 . This is a "CBA/EBPA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 100214 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 7333997 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 432127799 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com