Provider Demographics
NPI:1780108639
Name:FULLER HOMES LLC
Entity type:Organization
Organization Name:FULLER HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ AGENCY NURSE
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:256-221-0041
Mailing Address - Street 1:1808 SCOBEE AVE SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-2407
Mailing Address - Country:US
Mailing Address - Phone:256-221-0041
Mailing Address - Fax:256-937-2002
Practice Address - Street 1:102 POPULUS DR
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-4802
Practice Address - Country:US
Practice Address - Phone:256-221-0041
Practice Address - Fax:256-937-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities