Provider Demographics
NPI:1073632006
Name:SULLIVAN, BRYAN DANIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DANIEL
Last Name:SULLIVAN
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 1:7835 MAIN ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7071
Mailing Address - Country:US
Mailing Address - Phone:763-494-4311
Mailing Address - Fax:
Practice Address - Street 1:7835 MAIN ST
Practice Address - Street 2:SUITE 230
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7071
Practice Address - Country:US
Practice Address - Phone:763-494-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor