Healthcare Provider Details

I. General information

NPI: 1740673680
Provider Name (Legal Business Name): LANCE FULSHER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W MAIN ST
KINGSLEY MI
49649-9481
US

IV. Provider business mailing address

409 W MAIN ST
KINGSLEY MI
49649-9481
US

V. Phone/Fax

Practice location:
  • Phone: 231-263-1001
  • Fax: 231-263-1002
Mailing address:
  • Phone: 231-263-1001
  • Fax: 231-263-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017119
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: