Healthcare Provider Details

I. General information

NPI: 1093337651
Provider Name (Legal Business Name): MR. SULLAVAN O'HARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2020
Last Update Date: 05/17/2020
Certification Date: 05/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOSPITAL DR
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

816 S CENTRAL ST
CENTRALIA MO
65240-1810
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-1255
  • Fax: 573-884-1010
Mailing address:
  • Phone: 816-786-0609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: