MEDICARE: ALAN J FULLER CADC II

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1213	GA

General Provider Information

NPI Number	:	1922567965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAN J FULLER CADC II

Provider Business Mailing Address
First Line	:	PO BOX 4236
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37802-4236
Country	:	US
Telephone Number	:	865-603-9889
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 OLD LAFAYETTE RD
Second Line	:
City	:	FT OGLETHORPE
State	:	GA
Zip	:	30742-3510
Country	:	US
Telephone Number	:	706-861-9390
Fax Number	:	706-866-4740

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

Provider Enumeration Date	:	03/19/2019
Last Update Date	:	03/19/2019

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