Provider Demographics
NPI:1306101563
Name:FULLER, CARLOS (LMBT# 11837)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:LMBT# 11837
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 ALLEGHANY ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3742
Mailing Address - Country:US
Mailing Address - Phone:704-492-6784
Mailing Address - Fax:
Practice Address - Street 1:1406 BEATTIES FORD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4550
Practice Address - Country:US
Practice Address - Phone:704-492-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMBT# 11837173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist