Basic Information
Provider Information | |||||||||
NPI: | 1790882926 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FULLER REHABILITATION AND CONSULTING SERVICES INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INDEPENDENT LIVING AIDS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 6064 WILMINGTON PIKE | ||||||||
Address2: | SUGARCREEK PLAZA SHOPPING CENTER | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454597006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378484300 | ||||||||
FaxNumber: | 9378484310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 2552910 | 05 | OH |   | MEDICAID |