Provider Demographics
NPI:1477857423
Name:FULLER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FULLER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:270-256-2932
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-0445
Mailing Address - Country:US
Mailing Address - Phone:270-274-9221
Mailing Address - Fax:270-955-2003
Practice Address - Street 1:227 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-2131
Practice Address - Country:US
Practice Address - Phone:270-274-9221
Practice Address - Fax:270-955-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100316910Medicaid