Healthcare Provider Details

I. General information

NPI: 1811028087
Provider Name (Legal Business Name): KURT B. FULK C. PED., BOC-O, CO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S BRENTWOOD BLVD STE A
SPRINGFIELD MO
65804-2534
US

IV. Provider business mailing address

638 SOMMER LN
BILLINGS MO
65610-8324
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-0887
  • Fax:
Mailing address:
  • Phone: 417-744-4152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: