Organization
HEALTHPORT P.A.
Active
Other names
PAIN RECOVERY CENTER OF TYLER
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH FULTS D.O. (PRESIDENT)
(903) 526-5000
Entity
Organization
Contact information
Practice address
4295 KINSEY DR, TYLER, TX 75703-1004
(903) 526-5000
(903) 526-5006
Mailing address
4295 KINSEY DR, TYLER, TX 75703-1004
(903) 526-5000
(903) 526-5006
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
—
—
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
Primary
—
—
208VP0014X
Interventional Pain Medicine Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0066SG
BCBS
TX
05
—
208679501
—
TX
Enumeration date
08/15/2008
Last updated
01/07/2013
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