Provider Demographics
NPI:1679529788
Name:SULLIVAN-BOL, KENNETH JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:SULLIVAN-BOL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:JAMES
Other - Last Name:SULLIVAN-BOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:345 ELM ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2265
Mailing Address - Country:US
Mailing Address - Phone:802-753-7930
Mailing Address - Fax:802-753-7924
Practice Address - Street 1:345 ELM ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2265
Practice Address - Country:US
Practice Address - Phone:802-753-7930
Practice Address - Fax:802-753-7924
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38-009348111N00000X
VT006.00614952251X0800X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU85252Medicare UPIN
ILL86134Medicare PIN