Basic Information
| Provider Information | |||||||||
| NPI: | 1063445526 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLER REHABILITATION AND CONSULTING SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FULLER REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 615 | ||||||||
| Address2: | |||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307360615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069656131 | ||||||||
| FaxNumber: | 7064131352 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 ROLLINS INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307362872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069656131 | ||||||||
| FaxNumber: | 7069653801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | GA | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | GA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 4581852 | 05 | TN | MEDICAID | 1063445526 | 05 | AL | MEDICAID | 000660074A | 05 | GA | MEDICAID |