Healthcare Provider Details

I. General information

NPI: 1073556544
Provider Name (Legal Business Name): BRIAN JAY FULLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
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: 708-705-9494
  • Fax: 708-221-7108
Mailing address:
  • Phone: 708-705-9494
  • Fax: 708-221-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: