Provider Demographics
NPI:1457468241
Name:SULLIVAN, SANDRA JANE (DC)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JANE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 N GALLOWAY AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6364
Mailing Address - Country:US
Mailing Address - Phone:972-270-5700
Mailing Address - Fax:972-270-0047
Practice Address - Street 1:2929 N GALLOWAY AVE
Practice Address - Street 2:STE 109
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6364
Practice Address - Country:US
Practice Address - Phone:972-270-5700
Practice Address - Fax:972-270-0047
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6121111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX606007OtherBCBS PROVIDER #
TX350052215Medicare PIN
TX603784Medicare PIN