Individual
KENNETH DANIEL FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
9112 N POLK AVE, PORTLAND, OR 97203-2320
(503) 660-6154
Mailing address
9112 N POLK AVE, PORTLAND, OR 97203-2320
(503) 660-6154
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
12913
OR
Other
Enumeration date
07/02/2020
Last updated
07/02/2020
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