Provider Demographics
NPI:1114100880
Name:SULLIVAN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:SULLIVAN CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC DABCO
Authorized Official - Phone:563-556-8600
Mailing Address - Street 1:2699 JOHN F KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2838
Mailing Address - Country:US
Mailing Address - Phone:563-556-8600
Mailing Address - Fax:563-556-8600
Practice Address - Street 1:2699 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2838
Practice Address - Country:US
Practice Address - Phone:563-556-8600
Practice Address - Fax:563-556-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04001111N00000X
IAA05477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI16442Medicare PIN