Basic Information
| Provider Information | |||||||||
| NPI: | 1083711204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLER REHABILITATION AND CONSULTING SERVICES INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FULLER REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 90 ALEXANDRIA PIKE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | FORT THOMAS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410754102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594425191 | ||||||||
| FaxNumber: | 8594425473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | CARTER | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7069650352 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FULLER REHABILITATION AND CONSULTING SERVICES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 2552910 | 05 | OH | MEDICAID | 200482310A | 05 | IN | MEDICAID | 0952950009 | 01 | KY | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 90001918 | 05 | KY | MEDICAID |