Organization
FULLER HEALTH GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIAN JAY FULLER DC (PRESIDENT)
(708) 705-9494
Entity
Organization
Contact information
Practice address
12 W MAPLE ST, CHICAGO, IL 60610-4691
(312) 587-3500
Mailing address
PO BOX 349, OAK PARK, IL 60303-0349
(708) 705-9494
(708) 386-2768
Taxonomy
Speciality
Code
Description
License number
State
111NN1001X
Nutrition Chiropractor
Primary
038010329
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1073556544
BLUE CROSS AND BLUE SHIELD OF ILLINOIS
IL
Enumeration date
12/08/2008
Last updated
12/08/2008
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