MEDICARE: CHRISTINE LOUISE SULLIVAN DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3767012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912975103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE LOUISE SULLIVAN DC

Provider Business Mailing Address
First Line	:	PO BOX 645
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	58120-0645
Country	:	US
Telephone Number	:	262-642-7404
Fax Number	:	262-642-7493

Provider Business Practice Location Address
First Line	:	3161 MAIN ST
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-1151
Country	:	US
Telephone Number	:	262-642-7404
Fax Number	:	262-642-7493

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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