Healthcare Provider Details

I. General information

NPI: 1407891815
Provider Name (Legal Business Name): FULLER-ROBERTS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 WILBORN AVE
SOUTH BOSTON VA
24592-1630
US

IV. Provider business mailing address

2212 WILBORN AVE
SOUTH BOSTON VA
24592-1630
US

V. Phone/Fax

Practice location:
  • Phone: 434-572-8921
  • Fax: 434-572-2063
Mailing address:
  • Phone: 434-572-8921
  • Fax: 434-572-2063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTY NEWTON II
Title or Position: OFFICE MANAGER
Credential:
Phone: 434-572-8921