Healthcare Provider Details

I. General information

NPI: 1528110004
Provider Name (Legal Business Name): DR. TERRENCE J. SULLIVAN D.C. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 CALIMESA BLVD SUITE F
CALIMESA CA
92320-1131
US

IV. Provider business mailing address

1007 CALIMESA BLVD SUITE F
CALIMESA CA
92320-1131
US

V. Phone/Fax

Practice location:
  • Phone: 909-795-8984
  • Fax: 909-795-8985
Mailing address:
  • Phone: 909-795-8984
  • Fax: 909-795-8985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number24230
License Number StateCA

VIII. Authorized Official

Name: DR. TERRENCE JERALD SULLIVAN
Title or Position: OFFICE MANAGER
Credential: D.C
Phone: 909-795-8984