Provider Demographics
NPI:1114790177
Name:FULCO AND HALL PERFORMANCE AND THERAPY LLC
Entity Type:Organization
Organization Name:FULCO AND HALL PERFORMANCE AND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULCO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CERT DN
Authorized Official - Phone:318-754-7367
Mailing Address - Street 1:138 E RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9427
Mailing Address - Country:US
Mailing Address - Phone:318-754-7367
Mailing Address - Fax:
Practice Address - Street 1:1156 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3026
Practice Address - Country:US
Practice Address - Phone:318-200-0386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty