Provider Demographics
NPI:1164294948
Name:FULLER'S ORTHOPEDIC
Entity Type:Organization
Organization Name:FULLER'S ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:434-529-8882
Mailing Address - Street 1:36 PARKWAY LN STE 122
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2430
Mailing Address - Country:US
Mailing Address - Phone:540-917-0006
Mailing Address - Fax:540-917-0506
Practice Address - Street 1:36 PARKWAY LN STE 122
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2430
Practice Address - Country:US
Practice Address - Phone:540-917-0006
Practice Address - Fax:540-917-0506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULLER'S ORTHOPEDIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist