Basic Information
| Provider Information | |||||||||
| NPI: | 1346821881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SARAH CANNON 0413 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2550 | ||||||||
| Address2: | |||||||||
| City: | ROWLETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750302550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 LAKE VIS W | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND VILLAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750776807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | CANNON | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4698264723 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CSFA | ||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.