Provider Demographics
NPI:1881406684
Name:SULLIVAN, KENT
Entity type:Individual
Prefix:MR
First Name:KENT
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:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:BONDURANT
Mailing Address - State:IA
Mailing Address - Zip Code:50035-0235
Mailing Address - Country:US
Mailing Address - Phone:515-250-9394
Mailing Address - Fax:
Practice Address - Street 1:206 MAIN ST SE
Practice Address - Street 2:
Practice Address - City:BONDURANT
Practice Address - State:IA
Practice Address - Zip Code:50035-1048
Practice Address - Country:US
Practice Address - Phone:515-250-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC127019171W00000X, 171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor