Healthcare Provider Details

I. General information

NPI: 1649384983
Provider Name (Legal Business Name): JAMES FRED SULLIVAN RKT CEP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

110 HUNTER LEE LN
STONEWALL LA
71078-4800
US

V. Phone/Fax

Practice location:
  • Phone: 318-424-6106
  • Fax: 318-429-5727
Mailing address:
  • Phone: 318-925-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number621
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: