Provider Demographics
NPI:1104997071
Name:FULLERTON, THOMAS P (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:FULLERTON
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 1:720 2ND ST E
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4678
Mailing Address - Country:US
Mailing Address - Phone:406-257-7463
Mailing Address - Fax:406-257-7466
Practice Address - Street 1:720 2ND ST E
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4678
Practice Address - Country:US
Practice Address - Phone:406-257-7463
Practice Address - Fax:406-257-7466
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0161041Medicaid