Healthcare Provider Details

I. General information

NPI: 1104808385
Provider Name (Legal Business Name): SULLIVAN CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SEMORA RD
ROXBORO NC
27573-6201
US

IV. Provider business mailing address

PO BOX 1091
ROXBORO NC
27573-1091
US

V. Phone/Fax

Practice location:
  • Phone: 336-599-6771
  • Fax: 336-599-6494
Mailing address:
  • Phone: 336-599-6771
  • Fax: 336-599-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1757
License Number StateNC

VIII. Authorized Official

Name: GARY J SULLIVAN
Title or Position: GEN PARTNER
Credential: DC
Phone: 336-599-6771