| Organization Name: | MICHAEL JAY FULLER |
| NPI Number: | 1669776266 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MICHAEL JAY FULLER (BUSINESS OWNER) |
| Mailing Address: | 149c Logan Ct Angier |
| State: | NC US |
| Postal Code: | 275018579 |
| Phone Number: | 9193311189 |
| Fax Number: | 9193312425 |
| NPI Enumeration Date: | 12/23/2010 |
| NPI Last Update Date: | 01/12/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |