Provider Demographics
NPI:1396071502
Name:FULCHER, MARK (BS, LMT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FULCHER
Suffix:
Gender:M
Credentials:BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CAPAC RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1111
Mailing Address - Country:US
Mailing Address - Phone:810-724-0996
Mailing Address - Fax:810-724-4343
Practice Address - Street 1:125 E CAPAC RD
Practice Address - Street 2:SUITE B
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-1111
Practice Address - Country:US
Practice Address - Phone:810-724-0996
Practice Address - Fax:810-724-4343
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist