Healthcare Provider Details

I. General information

NPI: 1962647792
Provider Name (Legal Business Name): FULLER HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 W MAPLE ST
CHICAGO IL
60610-4691
US

IV. Provider business mailing address

PO BOX 349
OAK PARK IL
60303-0349
US

V. Phone/Fax

Practice location:
  • Phone: 312-587-3500
  • Fax:
Mailing address:
  • Phone: 708-705-9494
  • Fax: 708-386-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038010329
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN JAY FULLER
Title or Position: PRESIDENT
Credential: DC
Phone: 708-705-9494