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General NPI Number Information
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NPI Number | 1063421147
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Entity Type | Individual
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Provider Name | KIM KEVIN FULLER D.C.
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Gender | Male
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Dates
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Enumeration Date | 08/06/2006
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 106 WIMBLEDON SQ
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4931
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Country | US
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Telephone | 757-436-1037
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Fax | 757-547-4031
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Provider Business Mailing Address
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Address Line | 449 BROAD BEND CIR
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City | CHESAPEAKE
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State | VA
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Zip | 23320-9292
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Country | US
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Telephone | 757-436-3473
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 0104000403
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License Number State | VA
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