Provider Demographics
NPI:1336290261
Name:FULLERTON, MARK B (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-1849
Mailing Address - Country:US
Mailing Address - Phone:864-476-2200
Mailing Address - Fax:864-476-0757
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-1849
Practice Address - Country:US
Practice Address - Phone:864-476-2200
Practice Address - Fax:864-476-0757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1130111N00000X
PADC-002887-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1130Medicaid