Individual
MARK A FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2215 W WILLOW KNOLLS DRIVE, APT 503A, PEORIA, IL 61614-1446
(217) 330-0928
Mailing address
2215 W WILLOW KNOLLS DR APT 503A, PEORIA, IL 61614-1446
(217) 330-0928
Taxonomy
Speciality
Code
Description
License number
State
344600000X
Taxi
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
82-2237856
—
IL
Enumeration date
07/25/2017
Last updated
07/21/2022
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