Provider Demographics
NPI:1104923325
Name:FULLER REHABILITATION AND CONSULTING SERVICES INC.
Entity type:Organization
Organization Name:FULLER REHABILITATION AND CONSULTING SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-965-0323
Mailing Address - Street 1:529 ROLLINS INDUSTRIAL BLVD
Mailing Address - Street 2:P.O. BOX 615
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-2872
Mailing Address - Country:US
Mailing Address - Phone:706-965-6131
Mailing Address - Fax:706-965-3801
Practice Address - Street 1:412 CROSSTOWN RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2915
Practice Address - Country:US
Practice Address - Phone:770-486-7577
Practice Address - Fax:770-486-7556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-05-08
Deactivation Date:2009-02-05
Deactivation Code:
Reactivation Date:2009-05-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000660074AMedicaid
GA000660074AMedicaid