Provider Demographics
NPI:1528110004
Name:DR. TERRENCE J. SULLIVAN D.C. INC.
Entity type:Organization
Organization Name:DR. TERRENCE J. SULLIVAN D.C. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:JERALD
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-795-8984
Mailing Address - Street 1:1007 CALIMESA BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-1131
Mailing Address - Country:US
Mailing Address - Phone:909-795-8984
Mailing Address - Fax:909-795-8985
Practice Address - Street 1:1007 CALIMESA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1131
Practice Address - Country:US
Practice Address - Phone:909-795-8984
Practice Address - Fax:909-795-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0242301Medicare ID - Type Unspecified
CAU60237Medicare UPIN