MEDICARE: CARLOS FULLER LMBT# 11837

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
1	173C00000X	Reflexologist	LMBT# 11837	NC

General Provider Information

NPI Number	:	1306101563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS FULLER LMBT# 11837

Provider Business Mailing Address
First Line	:	2401 ALLEGHANY ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-3742
Country	:	US
Telephone Number	:	704-492-6784
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-4550
Country	:	US
Telephone Number	:	704-492-6784
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	07/12/2012

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