1669207114 NPI number — DR. RACHEL CAROLINE SULLIVAN PT, DPT

Table of content: DR. RACHEL CAROLINE SULLIVAN PT, DPT (NPI 1669207114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669207114 NPI number — DR. RACHEL CAROLINE SULLIVAN PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
RACHEL
Provider Middle Name:
CAROLINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BREITENBACH
Provider Other First Name:
RACHEL
Provider Other Middle Name:
CAROLINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669207114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1645 FOREST HILL RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-1697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-960-7077
Provider Business Mailing Address Fax Number:
478-245-9079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1645 FOREST HILL RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-1697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-960-7077
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT017274 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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