Basic Information
| Provider Information | |||||||||
| NPI: | 1366461519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLY | ||||||||
| FirstName: | SUNIT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 KEENAN ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024722904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209847075 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 WILLARD ST | ||||||||
| Address2: | SUITE GA | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021691200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174714491 | ||||||||
| FaxNumber: | 6179840636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2827 | MA | Y | Chiropractic Providers | Chiropractor | 111N00000X | 5600 | CO | N | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | AA48946 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER | Y36967 | 01 | MA | BCBSMA | OTHER |