Provider Demographics
NPI:1215655915
Name:FULLER VISION, LLC
Entity type:Organization
Organization Name:FULLER VISION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:228-262-0266
Mailing Address - Street 1:2170 E PASS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3864
Mailing Address - Country:US
Mailing Address - Phone:228-262-0266
Mailing Address - Fax:
Practice Address - Street 1:2170 E PASS RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3864
Practice Address - Country:US
Practice Address - Phone:601-382-4365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty