1043227473 NPI number — MRS. LEAH MAE FULTON P.T.

Table of content: MRS. LEAH MAE FULTON P.T. (NPI 1043227473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043227473 NPI number — MRS. LEAH MAE FULTON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTON
Provider First Name:
LEAH
Provider Middle Name:
MAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRUDOP
Provider Other First Name:
LEAH
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043227473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1312 DORCHESTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNDELEIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60060-1054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-949-0983
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W WACKER DR
Provider Second Line Business Practice Location Address:
SUIE 820
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60606-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-640-0329
Provider Business Practice Location Address Fax Number:
847-375-8357
Provider Enumeration Date:
08/01/2006

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: 225100000X , with the licence number:  070-009674 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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