Provider Demographics
NPI:1962647792
Name:FULLER HEALTH GROUP LLC
Entity Type:Organization
Organization Name:FULLER HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-0349
Mailing Address - Country:US
Mailing Address - Phone:708-705-9494
Mailing Address - Fax:708-386-2768
Practice Address - Street 1:12 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-4691
Practice Address - Country:US
Practice Address - Phone:312-587-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010329111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073556544OtherBLUE CROSS AND BLUE SHIELD OF ILLINOIS