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NPI Code Detail

MEDICARE: VICTOR P FULLER

MEDICARE: VICTOR P FULLER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1003110628
Entity Type Code : Individual
Provider Name (Legal Business Name) : VICTOR P FULLER
Provider Business Mailing Address
First Line : 16278 PRINCE DR
Second Line :
City : SOUTH HOLLAND
State : IL
Zip : 60473-3233
Country : US
Telephone Number : 708-754-8815
Fax Number :
Provider Business Practice Location Address
First Line : 19530 KEDZIE AVE
Second Line :
City : FLOSSMOOR
State : IL
Zip : 60422-1778
Country : US
Telephone Number : 708-754-8815
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/23/2010
Last Update Date : 12/23/2010

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Directions to “ VICTOR P FULLER ” Practice Location

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