Provider Demographics
NPI:1053320887
Name:SULACK, PETER C (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:SULACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11151 KINGSTON PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2853
Mailing Address - Country:US
Mailing Address - Phone:865-675-2050
Mailing Address - Fax:865-675-2051
Practice Address - Street 1:11151 KINGSTON PIKE
Practice Address - Street 2:SUITE C
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2853
Practice Address - Country:US
Practice Address - Phone:865-675-2050
Practice Address - Fax:865-675-2051
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001857111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033747OtherBCBS BILLING PROVIDER #
TN4033748OtherBCBS RENDERING PROVIDER #
TNU90155Medicare UPIN
TN4033748OtherBCBS RENDERING PROVIDER #
TN2972274Medicare ID - Type UnspecifiedPROVIDER RENDERING ID