Provider Demographics
NPI:1962530014
Name:MANDIC O SULLIVAN, LINDA IRENE (DC)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:IRENE
Last Name:MANDIC O SULLIVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:TILLSON
Mailing Address - State:NY
Mailing Address - Zip Code:12486
Mailing Address - Country:US
Mailing Address - Phone:845-658-9345
Mailing Address - Fax:845-339-2143
Practice Address - Street 1:10 SPRING ST
Practice Address - Street 2:
Practice Address - City:TILLSON
Practice Address - State:NY
Practice Address - Zip Code:12486
Practice Address - Country:US
Practice Address - Phone:845-658-9345
Practice Address - Fax:845-339-2143
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX47991Medicare PIN