1912492422 NPI number — BILL JOE FULLEN II PT, DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912492422 NPI number — BILL JOE FULLEN II PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLEN
Provider First Name:
BILL
Provider Middle Name:
JOE
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULLEN
Provider Other First Name:
BILLY
Provider Other Middle Name:
JOE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1912492422
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2405 N COLUMBUS ST STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43130-8189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-687-3346
Provider Business Mailing Address Fax Number:
740-689-9736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 N COLUMBUS ST STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43130-8189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-687-3346
Provider Business Practice Location Address Fax Number:
740-689-9736
Provider Enumeration Date:
06/27/2018

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:  PT296443 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: PT017529 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT017529 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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