Provider Demographics
NPI:1083820740
Name:SULLIVAN, GARY J (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
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:PO BOX 1091
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-1091
Mailing Address - Country:US
Mailing Address - Phone:336-599-6771
Mailing Address - Fax:336-599-6494
Practice Address - Street 1:30 SEMORA RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-6201
Practice Address - Country:US
Practice Address - Phone:336-599-6771
Practice Address - Fax:336-599-6494
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2447959Medicare PIN