Basic Information
| Provider Information | |||||||||
| NPI: | 1134290331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 CROSS CREEK CT | ||||||||
| Address2: | APT B | ||||||||
| City: | CENTRAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296304108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312615569 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12023 NORTH RADIO STATION RD. | ||||||||
| Address2: | STE A | ||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296780929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649850770 | ||||||||
| FaxNumber: | 8649851770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5295 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.