Healthcare Provider Details

I. General information

NPI: 1164334256
Provider Name (Legal Business Name): FULLERTON SH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 SUNNY CREST DR
FULLERTON CA
92835-3628
US

IV. Provider business mailing address

1925 SUNNY CREST DR
FULLERTON CA
92835-3628
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-1999
  • Fax: 714-992-4186
Mailing address:
  • Phone: 714-992-1999
  • Fax: 714-992-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: KYLE HIBBLER
Title or Position: VP OF BUSINESS
Credential:
Phone: 503-391-9999