Provider Demographics
NPI:1689095333
Name:FULLY CORPORATION
Entity Type:Organization
Organization Name:FULLY CORPORATION
Other - Org Name:FAITHFULNESS ,UNDERSTANDING, LEARNING & LOVING YOUTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PETULA
Authorized Official - Middle Name:LORAINE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-327-1982
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:CALVARY
Mailing Address - State:GA
Mailing Address - Zip Code:39829-0057
Mailing Address - Country:US
Mailing Address - Phone:229-872-3113
Mailing Address - Fax:229-872-3642
Practice Address - Street 1:416 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-8414
Practice Address - Country:US
Practice Address - Phone:229-872-3113
Practice Address - Fax:229-872-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency