=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013365659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINALD FULWILEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2016
-----------------------------------------------------
Last Update Date | 05/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 WEST MAIN ST SUITE 12 3RD FL
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39350-0245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-331-3619
-----------------------------------------------------
Fax | 601-510-9052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 245
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-331-3619
-----------------------------------------------------
Fax | 601-510-9052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | R857836
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------