Provider Demographics
NPI:1124384938
Name:CHIRO-MED & REHAB
Entity Type:Organization
Organization Name:CHIRO-MED & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SULLIVAN-BOL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:802-753-7930
Mailing Address - Street 1:655 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2870
Mailing Address - Country:US
Mailing Address - Phone:802-753-7930
Mailing Address - Fax:802-753-7924
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2870
Practice Address - Country:US
Practice Address - Phone:802-753-7930
Practice Address - Fax:802-753-7924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006.0061495111N00000X, 2251X0800X
IL38-009348111N00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1020447Medicaid
VT1020447Medicaid
ILL86134Medicare PIN