Provider Demographics
NPI:1770600439
Name:SULLIVAN CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:SULLIVAN CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-542-3400
Mailing Address - Street 1:311 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2705
Mailing Address - Country:US
Mailing Address - Phone:248-542-3400
Mailing Address - Fax:248-542-3466
Practice Address - Street 1:311 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2705
Practice Address - Country:US
Practice Address - Phone:248-542-3400
Practice Address - Fax:248-542-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F351647951Medicare ID - Type Unspecified
MI95-0-F3-386-0Medicare UPIN