Provider Demographics
NPI:1487350799
Name:FULLER HEALTH & NUTRITION, LLC
Entity type:Organization
Organization Name:FULLER HEALTH & NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:970-640-8023
Mailing Address - Street 1:2873 FALL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503-3057
Mailing Address - Country:US
Mailing Address - Phone:970-640-8023
Mailing Address - Fax:
Practice Address - Street 1:2873 FALL CREEK DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81503-3057
Practice Address - Country:US
Practice Address - Phone:970-640-8023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1881362663OtherI AM THE ONLY PROVIDER