Provider Demographics
NPI:1285760033
Name:FULLMER, CHAD B (MPT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:B
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 E THREE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1296
Mailing Address - Country:US
Mailing Address - Phone:801-635-6602
Mailing Address - Fax:
Practice Address - Street 1:5314 RIVER RUN DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5691
Practice Address - Country:US
Practice Address - Phone:801-426-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010369225100000X
UT4877705-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist