Provider Demographics
NPI:1215362850
Name:FULLER'S ORTHOPEDIC
Entity Type:Organization
Organization Name:FULLER'S ORTHOPEDIC
Other - Org Name:INDEPENDENCE PROSTHETICS-ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
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 1:612 RIO RD W STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1412
Mailing Address - Country:US
Mailing Address - Phone:434-529-8882
Mailing Address - Fax:434-529-8942
Practice Address - Street 1:612 RIO RD W STE 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1412
Practice Address - Country:US
Practice Address - Phone:434-529-8882
Practice Address - Fax:434-529-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QA0900XAmbulatory Health Care FacilitiesClinic/CenterAmputee