Healthcare Provider Details

I. General information

NPI: 1356487367
Provider Name (Legal Business Name): FULLER LIFE CHIROPRACTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 HWY 19 NORTH
THOMASTON GA
30286
US

IV. Provider business mailing address

PO BOX 307
MANCHESTER GA
31816
US

V. Phone/Fax

Practice location:
  • Phone: 678-432-4755
  • Fax: 678-432-4753
Mailing address:
  • Phone: 678-432-4755
  • Fax: 678-432-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: RONALD FULLER
Title or Position: PRESIDENT
Credential: DC
Phone: 678-432-4755