Healthcare Provider Details

I. General information

NPI: 1801727441
Provider Name (Legal Business Name): FULTON SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174-0738
US

IV. Provider business mailing address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174-0738
US

V. Phone/Fax

Practice location:
  • Phone: 386-267-2965
  • Fax: 386-603-6007
Mailing address:
  • Phone: 386-267-2965
  • Fax: 386-603-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRENT NELSON FULTON
Title or Position: PRESIDENT
Credential: MD
Phone: 386-267-2965