MEDICARE: FULLER HEALTH GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NN1001X	Nutrition Chiropractor	038010329	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073556544	OTHER	IL	BLUE CROSS AND BLUE SHIELD OF ILLINOIS

General Provider Information

NPI Number	:	1962647792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLER HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX 349
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60303-0349
Country	:	US
Telephone Number	:	708-705-9494
Fax Number	:	708-386-2768

Provider Business Practice Location Address
First Line	:	12 W MAPLE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-4691
Country	:	US
Telephone Number	:	312-587-3500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN JAY FULLER
Credential	:	DC
Telephone Number	:	708-705-9494

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	12/08/2008

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Directions to “FULLER HEALTH GROUP LLC ” Practice Location

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