Provider Demographics
NPI:1144865957
Name:FULLER, ERIC ALAN
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ALAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAST 2ND STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161
Mailing Address - Country:US
Mailing Address - Phone:706-234-2001
Mailing Address - Fax:
Practice Address - Street 1:700 EAST 2ND STREET
Practice Address - Street 2:SUITE C
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161
Practice Address - Country:US
Practice Address - Phone:706-234-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHAP000318237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter