Provider Demographics
NPI:1104295161
Name:MATTHEWS CANNON ENTERPRISE LLC
Entity type:Organization
Organization Name:MATTHEWS CANNON ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-262-8609
Mailing Address - Street 1:212 N LAUDERDALE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3618
Mailing Address - Country:US
Mailing Address - Phone:901-626-1178
Mailing Address - Fax:901-544-9988
Practice Address - Street 1:212 N LAUDERDALE ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3618
Practice Address - Country:US
Practice Address - Phone:901-626-1178
Practice Address - Fax:901-544-9988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATTHEWS CANNON ENTERPRISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care