Provider Demographics
NPI:1770341588
Name:FULLER PHYSICAL THERAPY AND WELLNESS, LLC
Entity type:Organization
Organization Name:FULLER PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-262-6372
Mailing Address - Street 1:4240 E HOBACK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8838
Mailing Address - Country:US
Mailing Address - Phone:307-262-6372
Mailing Address - Fax:
Practice Address - Street 1:3510 SOUTH PARK DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-262-6372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy