Healthcare Provider Details

I. General information

NPI: 1124028634
Provider Name (Legal Business Name): JAMES C FULLER PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31200 23RD AVE SOUTH
FEDERAL WAY WA
98003
US

IV. Provider business mailing address

PO BOX 6225
FEDERAL WAY WA
98063
US

V. Phone/Fax

Practice location:
  • Phone: 253-839-3403
  • Fax: 253-839-3412
Mailing address:
  • Phone: 253-839-3403
  • Fax: 253-839-3412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3076
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT3076
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: