Provider Demographics
NPI:1386934669
Name:FULLER, ADAM JOSHUA (LAC)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:JOSHUA
Last Name:FULLER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 TEXAS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3722
Mailing Address - Country:US
Mailing Address - Phone:619-518-4222
Mailing Address - Fax:
Practice Address - Street 1:5005 TEXAS ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3722
Practice Address - Country:US
Practice Address - Phone:619-518-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14009171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist