Basic Information
| Provider Information | |||||||||
| NPI: | 1043578875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELIA A. FULLER, O.D., L.L.C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHELIA FULLER OD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 339 N LEXINGTON SPRINGMILL RD | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195252060 | ||||||||
| FaxNumber: | 4195299060 | ||||||||
| Practice Location | |||||||||
| Address1: | 339 N LEXINGTON SPRINGMILL RD | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195252060 | ||||||||
| FaxNumber: | 4195299060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 07/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | SHELIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4195252060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901-T1771 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.