Provider Demographics
NPI:1093868119
Name:SULLIVAN, MICHAEL THOMAS (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 OLD ROSEBUD ROAD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-263-8833
Mailing Address - Fax:859-264-1175
Practice Address - Street 1:2716 OLD ROSEBUD ROAD
Practice Address - Street 2:SUITE 230
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-263-8833
Practice Address - Fax:859-264-1175
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5038111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor