Provider Demographics
NPI:1740673680
Name:FULSHER, LANCE (DPT)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:
Last Name:FULSHER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2035
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2035
Mailing Address - Country:US
Mailing Address - Phone:231-944-7846
Mailing Address - Fax:231-346-6013
Practice Address - Street 1:3435 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5063
Practice Address - Country:US
Practice Address - Phone:248-743-1234
Practice Address - Fax:248-743-1237
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist