Provider Demographics
NPI:1659550085
Name:MARK B FULLERTON
Entity Type:Organization
Organization Name:MARK B FULLERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-476-2200
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1130Medicaid