Provider Demographics
NPI:1689806358
Name:FULLER HEALTH GROUP SC
Entity Type:Organization
Organization Name:FULLER HEALTH GROUP SC
Other - Org Name:FULLER HEALTH GROUP PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-705-9494
Mailing Address - Street 1:1010 LAKE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1135
Mailing Address - Country:US
Mailing Address - Phone:312-801-0318
Mailing Address - Fax:708-221-7108
Practice Address - Street 1:1010 LAKE ST STE 400
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1135
Practice Address - Country:US
Practice Address - Phone:312-801-0318
Practice Address - Fax:708-221-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty