Provider Demographics
NPI:1588858229
Name:FULLER, REGGIE STANLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:REGGIE
Middle Name:STANLEY
Last Name:FULLER
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 1:4201 SUNSET DR APT 201
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-4512
Mailing Address - Country:US
Mailing Address - Phone:612-423-3158
Mailing Address - Fax:
Practice Address - Street 1:4027 37TH ST NW
Practice Address - Street 2:
Practice Address - City:MAPLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55358-3422
Practice Address - Country:US
Practice Address - Phone:612-423-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5014111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor