Provider Demographics
NPI:1063700722
Name:FULLER FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:FULLER FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RETHA
Authorized Official - Middle Name:H
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-256-1801
Mailing Address - Street 1:4045 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106
Mailing Address - Country:US
Mailing Address - Phone:713-256-1801
Mailing Address - Fax:832-413-5904
Practice Address - Street 1:4045 AVENUE B
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106
Practice Address - Country:US
Practice Address - Phone:713-256-1801
Practice Address - Fax:832-413-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10392207R00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty