=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780168344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID L SULLIVAN LADC PLMHP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2018
-----------------------------------------------------
Last Update Date | 09/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 S 70TH ST STE 101
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-1563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-202-9342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2742 S 39TH ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-202-9342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID L SULLIVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-202-9342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------