=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063659662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. CHRISTOPHER SHAWN FULLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2009
-----------------------------------------------------
Last Update Date | 01/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19515 STAMFORD DR
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-0904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-882-9228
-----------------------------------------------------
Fax | 281-516-0161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13280 NORTHWEST FWY SUITE F391
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77040-6029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-906-4455
-----------------------------------------------------
Fax | 281-516-0161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------