Provider Demographics
NPI:1063860427
Name:FULLER, CARL II
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:FULLER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 RIVERBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-8666
Mailing Address - Country:US
Mailing Address - Phone:910-536-9721
Mailing Address - Fax:
Practice Address - Street 1:88 RIVERBROOK RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-8666
Practice Address - Country:US
Practice Address - Phone:910-536-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5070171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor