Basic Information
| Provider Information | |||||||||
| NPI: | 1104923325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLER REHABILITATION AND CONSULTING SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INDEPENDENT LIVING AIDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 529 ROLLINS INDUSTRIAL BLVD | ||||||||
| Address2: | P.O. BOX 615 | ||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307362872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069656131 | ||||||||
| FaxNumber: | 7069653801 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 CROSSTOWN RD | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302692915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704867577 | ||||||||
| FaxNumber: | 7704867556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/05/2009 | ||||||||
| NPIReactivationDate: | 05/08/2009 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULLIS | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
| AuthorizedOfficialMiddleName: | PATRICIA | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7069650323 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 000660074A | 05 | GA | MEDICAID |