Healthcare Provider Details

I. General information

NPI: 1821562612
Provider Name (Legal Business Name): CHARLES BLAKE SULLIVAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 VILLAGE SQUARE DR STE A
PADUCAH KY
42001-7448
US

IV. Provider business mailing address

2255 OWENS CHAPEL RD
MELBER KY
42069-8814
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-5712
  • Fax:
Mailing address:
  • Phone: 270-703-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007479
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: