1811132145 NPI number — NEUROLIFE CHIROPRACTIC & FUNCTIONAL MEDICINE CENTER, P.C.

Table of content: DR. BRANDON MICHAEL SULLIVAN PHARMD (NPI 1053186114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811132145 NPI number — NEUROLIFE CHIROPRACTIC & FUNCTIONAL MEDICINE CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLIFE CHIROPRACTIC & FUNCTIONAL MEDICINE CENTER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811132145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1383 21ST AVE N
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58102-1841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-365-0999
Provider Business Mailing Address Fax Number:
701-298-3738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1383 21ST AVE N
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-365-0999
Provider Business Practice Location Address Fax Number:
701-298-3738
Provider Enumeration Date:
12/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DANDURAN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-365-0999

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  829 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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