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General NPI Number Information
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NPI Number | 1073795423
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Entity Type | Organization
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Legal Business Name | STANLEY FULLER
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Dates
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Enumeration Date | 11/28/2007
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Last Update Date | 11/28/2007
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Provider Practice Location Address
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Address Line | 117 N WAYNE ST
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City | FREMONT
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State | OH
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Zip | 43420-2431
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Country | US
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Telephone | 419-307-2984
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Fax |
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Provider Business Mailing Address
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Address Line | 117 N WAYNE ST
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City | FREMONT
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State | OH
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Zip | 43420-2431
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Country | US
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Telephone | 419-307-2984
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | MR. STANLEY B FULLER
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Credential |
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Telephone | 419-307-2984
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | PN 102037
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License Number State | OH
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