Healthcare Provider Details

I. General information

NPI: 1093071193
Provider Name (Legal Business Name): FULLER OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 2ND AVE SE
CULLMAN AL
35055-3514
US

IV. Provider business mailing address

210 2ND AVE SE
CULLMAN AL
35055-3514
US

V. Phone/Fax

Practice location:
  • Phone: 256-734-1121
  • Fax: 256-734-1991
Mailing address:
  • Phone: 256-734-1121
  • Fax: 256-734-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberS320TA285
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier051554145
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name: DR. WAYNE B FULLER
Title or Position: OWNER
Credential: O.D.
Phone: 256-734-1121