Healthcare Provider Details

I. General information

NPI: 1871966317
Provider Name (Legal Business Name): KHALFANI SULLIVAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

IV. Provider business mailing address

6801 GOODWIN ST
HYATTSVILLE MD
20784-2521
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-1000
  • Fax:
Mailing address:
  • Phone: 202-689-4212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001450-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: