Provider Demographics
NPI:1174988240
Name:SULLIVAN, TIMOTHY (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6028 WELDON SPRING PKWY
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-9103
Mailing Address - Country:US
Mailing Address - Phone:330-968-8085
Mailing Address - Fax:
Practice Address - Street 1:11339 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3623
Practice Address - Country:US
Practice Address - Phone:314-842-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016000617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor