Provider Demographics
NPI:1871547562
Name:JOHN J SULLIVAN CHIROPRACTOR INC
Entity type:Organization
Organization Name:JOHN J SULLIVAN CHIROPRACTOR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:337-984-9276
Mailing Address - Street 1:109 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6086
Mailing Address - Country:US
Mailing Address - Phone:337-984-9276
Mailing Address - Fax:337-984-9012
Practice Address - Street 1:109 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6086
Practice Address - Country:US
Practice Address - Phone:337-984-9276
Practice Address - Fax:337-984-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA783111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR88Medicare ID - Type Unspecified