Basic Information
| Provider Information | |||||||||
| NPI: | 1265578322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULLER LIFE CHIROPRACTIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784324755 | ||||||||
| FaxNumber: | 6784324753 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 C EASTBROOK BEND | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784324755 | ||||||||
| FaxNumber: | 6784324753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 01/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6784324755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FULLER LIFE CHIROPRACTICE CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.