Provider Demographics
NPI:1649384983
Name:SULLIVAN, JAMES FRED (RKT CEP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:FRED
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RKT CEP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:110 HUNTER LEE LN
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-4800
Mailing Address - Country:US
Mailing Address - Phone:318-925-3778
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-424-6106
Practice Address - Fax:318-429-5727
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA621226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist