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General NPI Number Information
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NPI Number | 1215362850
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Entity Type | Organization
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Legal Business Name | FULLER'S ORTHOPEDIC
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Dates
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Enumeration Date | 09/13/2013
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Last Update Date | 10/17/2023
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Provider Practice Location Address
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Address Line | 612 RIO RD W STE 5
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1412
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Country | US
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Telephone | 434-529-8882
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Fax | 434-529-8882
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Provider Business Mailing Address
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Address Line | 612 RIO RD W STE 5
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1412
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Country | US
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Telephone | 434-529-8882
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Fax | 434-529-8942
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRYAN CARROLL FULLER
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Credential | CPO
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Telephone | 434-529-8882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0900X
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Taxonomy Name | Amputee Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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