Provider Demographics
NPI:1356688071
Name:FULLER LIFE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:FULLER LIFE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-432-4755
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31816
Mailing Address - Country:US
Mailing Address - Phone:678-432-4755
Mailing Address - Fax:678-432-4753
Practice Address - Street 1:6298 VETERANS PARKWAY STE 10E
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909
Practice Address - Country:US
Practice Address - Phone:678-432-4755
Practice Address - Fax:678-432-4753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULLER LIFE CHIROPRACTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3272Medicare UPIN