MEDICARE: A FULLER LIFESTYLE GROUP HOME INC

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1760335582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A FULLER LIFESTYLE GROUP HOME INC

Provider Business Mailing Address
First Line	:	4349 BOAT CLUB DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-1202
Country	:	US
Telephone Number	:	904-894-9979
Fax Number	:	904-894-9979

Provider Business Practice Location Address
First Line	:	8567 CHERYL ANN LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-1272
Country	:	US
Telephone Number	:	904-894-9979
Fax Number	:	904-894-9979

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LORENZO JAMES FULLER
Credential	:
Telephone Number	:	904-894-9979

Provider Enumeration Date	:	02/19/2026
Last Update Date	:	02/19/2026

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