Provider Demographics
NPI:1174956775
Name:FULMER, RICHARD SEAN (LMT, CPT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SEAN
Last Name:FULMER
Suffix:
Gender:M
Credentials:LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BRUCE LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8713
Mailing Address - Country:US
Mailing Address - Phone:386-986-5125
Mailing Address - Fax:
Practice Address - Street 1:20 BRUCE LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-986-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59413174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist