Basic Information
| Provider Information | |||||||||
| NPI: | 1245528389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8096 RIVERS AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438182020 | ||||||||
| FaxNumber: | 8438182379 | ||||||||
| Practice Location | |||||||||
| Address1: | 1774 PAXVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291025071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034352494 | ||||||||
| FaxNumber: | 8034358765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2011 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1659 | SC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.