Healthcare Provider Details

I. General information

NPI: 1689806358
Provider Name (Legal Business Name): FULLER HEALTH GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKE ST STE 400
OAK PARK IL
60301-1135
US

IV. Provider business mailing address

1010 LAKE ST STE 400
OAK PARK IL
60301-1135
US

V. Phone/Fax

Practice location:
  • Phone: 312-801-0318
  • Fax: 708-221-7108
Mailing address:
  • Phone: 312-801-0318
  • Fax: 708-221-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

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