1609854744 NPI number — GARRY T FULLER D.C.

Table of content: GARRY T FULLER D.C. (NPI 1609854744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609854744 NPI number — GARRY T FULLER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
GARRY
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609854744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 N GREEN ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BROWNSBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46112-2421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-852-8885
Provider Business Mailing Address Fax Number:
317-852-7492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 N GREEN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BROWNSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46112-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-852-8885
Provider Business Practice Location Address Fax Number:
317-852-7492
Provider Enumeration Date:
01/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08001100 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100133800A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".