| Four-ten Enterprise, Llc | |
|
1540 Rice Rd Ste 400, Tyler, TX 75703-3223 | |
| (903) 597-9021 | |
| (903) 597-0840 |
| Full Name | Four-ten Enterprise, Llc |
|---|---|
| Type | Facility |
| Speciality | Chiropractor |
| Location | 1540 Rice Rd Ste 400, Tyler, Texas |
| Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619497401 | NPI | - | NPPES |
| 583248 | Other | TX | MEDICARE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 111N00000X | Chiropractor | 12808 (Texas) | Primary |
| Provider Name | Jimmy B Sullivan |
|---|---|
| Provider Type | Practitioner - Chiropractic |
| Provider Identifiers | NPI Number: 1619368941 PECOS PAC ID: 3971873118 Enrollment ID: I20170721000719 |
| Mailing Address | Practice Location Address |
|---|---|
| Four-ten Enterprise, Llc 1540 Rice Rd Ste 400, Tyler, TX 75703-3223 Ph: (903) 597-9021 | Four-ten Enterprise, Llc 1540 Rice Rd Ste 400, Tyler, TX 75703-3223 Ph: (903) 597-9021 |
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