Provider Demographics
NPI:1346785722
Name:FULL POTENTIAL. INC
Entity Type:Organization
Organization Name:FULL POTENTIAL. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-499-0359
Mailing Address - Street 1:700 W TOLEDO ST
Mailing Address - Street 2:P.O 187
Mailing Address - City:FREMONT
Mailing Address - State:IN
Mailing Address - Zip Code:46737-7606
Mailing Address - Country:US
Mailing Address - Phone:260-499-0359
Mailing Address - Fax:
Practice Address - Street 1:700 W TOLEDO ST
Practice Address - Street 2:P.O 187
Practice Address - City:FREMONT
Practice Address - State:IN
Practice Address - Zip Code:46737-7606
Practice Address - Country:US
Practice Address - Phone:260-499-0359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201404030-AMedicaid