Basic Information
Provider Information | |||||||||
NPI: | 1043445653 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FULLER REHABILITATION AND CONSULTING SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FULLER REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 615 | ||||||||
Address2: |   | ||||||||
City: | RINGGOLD | ||||||||
State: | GA | ||||||||
PostalCode: | 307360615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7069656131 | ||||||||
FaxNumber: | 7064131352 | ||||||||
Practice Location | |||||||||
Address1: | 3728 PHILIPS HWY | ||||||||
Address2: | SUITE 38 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322076840 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043993509 | ||||||||
FaxNumber: | 9043993507 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2009 | ||||||||
LastUpdateDate: | 05/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FULLER | ||||||||
AuthorizedOfficialFirstName: | CARTER | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
AuthorizedOfficialTelephone: | 7069650352 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FULLER REHABILITATION AND CONSULTING SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | FL | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 332BC3200X | 1313554 | FL | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.