Provider Demographics
NPI:1669919957
Name:FULCHER, BURKE KEITH
Entity type:Individual
Prefix:
First Name:BURKE
Middle Name:KEITH
Last Name:FULCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SAW RD
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-8541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 SAW RD
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023-8541
Practice Address - Country:US
Practice Address - Phone:704-223-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer