Provider Demographics
NPI:1407031677
Name:SULLIVAN CHIROPRACTIC & REHABILITATION, INC.
Entity Type:Organization
Organization Name:SULLIVAN CHIROPRACTIC & REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:978-921-4440
Mailing Address - Street 1:142 RANTOUL ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4241
Mailing Address - Country:US
Mailing Address - Phone:978-921-4440
Mailing Address - Fax:978-921-6349
Practice Address - Street 1:142 RANTOUL ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4241
Practice Address - Country:US
Practice Address - Phone:978-921-4440
Practice Address - Fax:978-921-6349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAX2069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39672OtherBCBS GROUP
MAY45503Medicare PIN