1417778325 NPI number — LIZ FULTZ, LLC

Table of content: (NPI 1417778325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417778325 NPI number — LIZ FULTZ, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIZ FULTZ, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1417778325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2676 STATE HIGHWAY 1654
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41168-8949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-807-6095
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 CARTER AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-7672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-230-9999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
FULTZ
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRIVATE PRACTICE OWNER
Authorized Official Telephone Number:
606-230-9999

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1598419285 . This is a "COUNSELOR" identifier . This identifiers is of the category "OTHER".




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