Healthcare Provider Details

I. General information

NPI: 1508113291
Provider Name (Legal Business Name): TIMOTHY JOHN SULLIVAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8013 L ST
OMAHA NE
68127-1734
US

IV. Provider business mailing address

7811 CRABAPPLE CT
LA VISTA NE
68128-3016
US

V. Phone/Fax

Practice location:
  • Phone: 402-592-7686
  • Fax:
Mailing address:
  • Phone: 402-210-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1726
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: