Provider Demographics
NPI:1508076829
Name:SULLIVAN, JAMES MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S RANCHO SANTA FE RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-3935
Mailing Address - Country:US
Mailing Address - Phone:760-727-7044
Mailing Address - Fax:760-727-6558
Practice Address - Street 1:702 S RANCHO SANTA FE RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-3935
Practice Address - Country:US
Practice Address - Phone:760-727-7044
Practice Address - Fax:760-727-6558
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16551111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16551Medicare ID - Type UnspecifiedSTATE LICENSE NUMBER