Provider Demographics
NPI:1689604407
Name:SULLIVAN, TERRENCE JERALD (DC)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:JERALD
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 1:1007 CALIMESA BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-1131
Mailing Address - Country:US
Mailing Address - Phone:909-795-8984
Mailing Address - Fax:
Practice Address - Street 1:1007 CALIMESA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1131
Practice Address - Country:US
Practice Address - Phone:909-795-8984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0242301Medicare ID - Type Unspecified
CAU60237Medicare UPIN