MEDICARE: MR. RONALD VAN FULLOVE II ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1649772948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONALD VAN FULLOVE II ATC

Provider Business Mailing Address
First Line	:	3219 COVERED BRIDGE DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-1513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 MYRON MASSEY BLVD
Second Line	:
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-2621
Country	:	US
Telephone Number	:	334-561-4052
Fax Number	:

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

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/02/2018

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