Provider Demographics
NPI:1083711204
Name:FULLER REHABILITATION AND CONSULTING SERVICES INC.
Entity Type:Organization
Organization Name:FULLER REHABILITATION AND CONSULTING SERVICES INC.
Other - Org Name:FULLER REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-965-0352
Mailing Address - Street 1:PO BOX 615
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-0615
Mailing Address - Country:US
Mailing Address - Phone:706-965-6131
Mailing Address - Fax:706-413-1352
Practice Address - Street 1:90 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE 10
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-4102
Practice Address - Country:US
Practice Address - Phone:859-442-5191
Practice Address - Fax:859-442-5473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULLER REHABILITATION AND CONSULTING SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KY332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552910Medicaid
IN200482310AMedicaid
KY0952950009OtherMEDICARE ID-TYPE UNSPECIFIED
KY90001918Medicaid