Basic Information
| Provider Information | |||||||||
| NPI: | 1083937999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTS | ||||||||
| FirstName: | RADA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 681478 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370681478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155916590 | ||||||||
| FaxNumber: | 6155916601 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313934494 | ||||||||
| FaxNumber: | 9313934616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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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 | 225100000X | 4467 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0446631 | 05 | TN | MEDICAID |