Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CHIRO10176 | GA |
NPI | 1285192633 |
---|---|
Provider Name | Dr. Martin Anthony Sullivan |
First Address | Brookhaven, GA 30319-3748 |
Second Address | Atlanta, GA 30342-2678 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2019 |
Last Update Date | 05/03/2019 |