Provider Demographics
NPI:1063421147
Name:FULLER, KIM KEVIN (DC)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:KEVIN
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 BROAD BEND CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-9292
Mailing Address - Country:US
Mailing Address - Phone:757-436-3473
Mailing Address - Fax:
Practice Address - Street 1:106 WIMBLEDON SQ
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4931
Practice Address - Country:US
Practice Address - Phone:757-436-1037
Practice Address - Fax:757-547-4031
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000403111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
350000266Medicare ID - Type Unspecified
T21716Medicare UPIN