Healthcare Provider Details

I. General information

NPI: 1124384938
Provider Name (Legal Business Name): CHIRO-MED & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 ELM ST
BENNINGTON VT
05201-2265
US

IV. Provider business mailing address

345 ELM ST
BENNINGTON VT
05201-2265
US

V. Phone/Fax

Practice location:
  • Phone: 802-753-7930
  • Fax: 802-753-7924
Mailing address:
  • Phone: 802-753-7930
  • Fax: 802-753-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006.0061495
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38-009348
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number006.0061495
License Number StateVT

VIII. Authorized Official

Name: DR. KENNETH JAMES SULLIVAN-BOL
Title or Position: PRESIDENT/ CEO
Credential: DC
Phone: 802-753-7930