Healthcare Provider Details

I. General information

NPI: 1477857423
Provider Name (Legal Business Name): FULLER PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 S MAIN ST
BEAVER DAM KY
42320-2131
US

IV. Provider business mailing address

PO BOX 445
HARTFORD KY
42347-0445
US

V. Phone/Fax

Practice location:
  • Phone: 270-274-9221
  • Fax: 270-955-2003
Mailing address:
  • Phone: 270-274-9221
  • Fax: 270-955-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID CHRISTOPHER FULLER
Title or Position: OWNER AND PHYSICAL THERAPIST
Credential: PT,DPT
Phone: 270-256-2932