Provider Demographics
NPI:1295810679
Name:SUNDA, TIMOTHY CLARK (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CLARK
Last Name:SUNDA
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 1:506 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1125
Mailing Address - Country:US
Mailing Address - Phone:859-887-3140
Mailing Address - Fax:859-887-3141
Practice Address - Street 1:506 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1125
Practice Address - Country:US
Practice Address - Phone:859-887-3140
Practice Address - Fax:859-887-3141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0750601Medicare ID - Type Unspecified
KYU09942Medicare UPIN