Provider Demographics
NPI:1730951161
Name:SULLIVAN, LANCE D
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:D
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 1:2765 CLUB HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1715
Mailing Address - Country:US
Mailing Address - Phone:614-439-0908
Mailing Address - Fax:
Practice Address - Street 1:2323 LAKE CLUB DR STE 106
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-3101
Practice Address - Country:US
Practice Address - Phone:614-439-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator