Provider Demographics
NPI:1528775582
Name:FULLER HEALTH CARE GOUP, PLLC
Entity type:Organization
Organization Name:FULLER HEALTH CARE GOUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:208-740-8808
Mailing Address - Street 1:709 S WASHINGTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617
Mailing Address - Country:US
Mailing Address - Phone:208-740-8808
Mailing Address - Fax:
Practice Address - Street 1:709 S WASHINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617
Practice Address - Country:US
Practice Address - Phone:208-740-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty