Healthcare Provider Details

I. General information

NPI: 1346994647
Provider Name (Legal Business Name): KEVIN ANDREW FULLER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GLENDON CT
BAKERSFIELD CA
93309-3630
US

IV. Provider business mailing address

1900 GLENDON CT
BAKERSFIELD CA
93309-3630
US

V. Phone/Fax

Practice location:
  • Phone: 661-204-5415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number75728
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16989
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: