Individual
CHARLES BLAKE SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPT
Contact information
Practice address
4645 VILLAGE SQUARE DR STE A, PADUCAH, KY 42001-7448
(270) 443-5712
Mailing address
2255 OWENS CHAPEL RD, MELBER, KY 42069-8814
(270) 703-4992
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
007479
KY
Other
Enumeration date
01/15/2019
Last updated
01/15/2019
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