Provider Demographics
NPI:1073795423
Name:STANLEY FULLER
Entity Type:Organization
Organization Name:STANLEY FULLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-307-2984
Mailing Address - Street 1:117 N WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2431
Mailing Address - Country:US
Mailing Address - Phone:419-307-2984
Mailing Address - Fax:
Practice Address - Street 1:117 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2431
Practice Address - Country:US
Practice Address - Phone:419-307-2984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 102037311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home