| Name: | Fuller Optical, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 19 Dec 2002 (22 years ago) |
| Entity Number: | 000-686-763 |
| Register Number: | 000686763 |
| County: | Cullman |
| Place of Formation: | Cullman County |
| Principal Address: | CULLMAN, AL |
| Registered Office Street Address: | 210 2ND AVE SECULLMAN, AL 35055 |
| Registered Office Street Address ZIP Code: | 35055 |
Activities
OPTICAL/OPTOMETRY SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1093071193 | 2012-04-03 | 2012-04-03 | 210 2ND AVE SE, CULLMAN, AL, 350553514, US | 210 2ND AVE SE, CULLMAN, AL, 350553514, US | |||||||||||||||||||||||||
|
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| Phone | +1 256-734-1121 |
| Fax | 2567341991 |
Authorized person
| Name | DR. WAYNE B FULLER |
| Role | OWNER |
| Phone | 2567341121 |
Taxonomy
| Taxonomy Code | 305S00000X - Point of Service |
| License Number | S320TA285 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | 051554145 |
| State | AL |
| Name | Role |
|---|---|
| FULLER, WAYNE B | Agent |
| Name | Role |
|---|---|
| FULLER, WAYNE B | Member |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
