Provider Demographics
NPI:1700267150
Name:SULLIVAN, CHUCK
Entity type:Individual
Prefix:
First Name:CHUCK
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5575 POPLAR AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3857
Mailing Address - Country:US
Mailing Address - Phone:901-763-0909
Mailing Address - Fax:
Practice Address - Street 1:5575 POPLAR AVE STE 702
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3857
Practice Address - Country:US
Practice Address - Phone:901-763-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist