=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114100880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SULLIVAN CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2007
-----------------------------------------------------
Last Update Date | 06/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2699 JOHN F KENNEDY RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-8600
-----------------------------------------------------
Fax | 563-556-8600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2699 JOHN F KENNEDY RD
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52002-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-556-8600
-----------------------------------------------------
Fax | 563-556-8600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER CHIROPRACTOR
-----------------------------------------------------
Name | DR. SAMUEL JAMES SULLIVAN
-----------------------------------------------------
Credential | DC DABCO
-----------------------------------------------------
Telephone | 563-556-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | A05477
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 04001
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------