Provider Demographics
NPI:1992830095
Name:PETER CHARLES SULACK D.C.
Entity Type:Organization
Organization Name:PETER CHARLES SULACK D.C.
Other - Org Name:EXODUS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:EASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-675-2050
Mailing Address - Street 1:10910 KINGSTON PIKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2931
Mailing Address - Country:US
Mailing Address - Phone:865-675-2050
Mailing Address - Fax:
Practice Address - Street 1:10910 KINGSTON PIKE
Practice Address - Street 2:SUITE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2931
Practice Address - Country:US
Practice Address - Phone:865-675-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033747OtherBLUE CROSS GROUP BILLING
TN3972513Medicare ID - Type UnspecifiedMEDICARE GROUP BILLING