Provider Demographics
NPI:1396795365
Name:SULLIVAN, DAVID ROLLAND (LAC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ROLLAND
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17777 ST CROIX TRAIL NORTH
Mailing Address - Street 2:
Mailing Address - City:MARINE ON ST CROIX
Mailing Address - State:MN
Mailing Address - Zip Code:55047
Mailing Address - Country:US
Mailing Address - Phone:651-433-5458
Mailing Address - Fax:
Practice Address - Street 1:17777 ST CROIX TRAIL NORTH
Practice Address - Street 2:
Practice Address - City:MARINE ON ST CROIX
Practice Address - State:MN
Practice Address - Zip Code:55047
Practice Address - Country:US
Practice Address - Phone:651-433-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1288171100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No171100000XOther Service ProvidersAcupuncturist