Healthcare Provider Details

I. General information

NPI: 1225536329
Provider Name (Legal Business Name): BENJAMIN SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HILLS BEACH RD
BIDDEFORD ME
04005-9526
US

IV. Provider business mailing address

210 OEHMAN BLVD
CHEEKTOWAGA NY
14225-1643
US

V. Phone/Fax

Practice location:
  • Phone: 716-580-0705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: