Provider Demographics
NPI:1265662282
Name:SULLIVAN
Entity Type:Organization
Organization Name:SULLIVAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-375-2579
Mailing Address - Street 1:8787 E BEBE RD
Mailing Address - Street 2:
Mailing Address - City:SOLON SPRINGS
Mailing Address - State:WI
Mailing Address - Zip Code:54873-8122
Mailing Address - Country:US
Mailing Address - Phone:715-375-2579
Mailing Address - Fax:715-375-2579
Practice Address - Street 1:8787 E BEBE RD
Practice Address - Street 2:
Practice Address - City:SOLON SPRINGS
Practice Address - State:WI
Practice Address - Zip Code:54873-8122
Practice Address - Country:US
Practice Address - Phone:715-375-2579
Practice Address - Fax:715-375-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment