Michael Charles Fuller Jr.

Primary specialty

Rehabilitation PractitionerTaxonomy code 225400000X

License

17771 Issued in CA

Practice address

14763 Manzanita Rd
Beaumont, CA 92223-3026

Phone

(909) 433-9824

NPI assigned

Oct 1, 2015

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1443657600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1755734400000",
    "number": "1083084115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1076 SANTO ANTONIO DR",
            "city": "COLTON",
            "state": "CA",
            "postal_code": "923248103",
            "telephone_number": "909-433-9824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14763 MANZANITA RD",
            "city": "BEAUMONT",
            "state": "CA",
            "postal_code": "922233026",
            "telephone_number": "909-433-9824"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1076 Santo Antonio Dr",
            "address_purpose": "LOCATION",
            "city": "Colton",
            "state": "CA",
            "postal_code": "923248103",
            "country_code": "US",
            "telephone_number": "909-433-9824",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FULLER",
        "first_name": "MICHAEL",
        "middle_name": "CHARLES",
        "name_suffix": "Jr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2015-10-01",
        "last_updated": "2025-08-21",
        "certification_date": "2025-08-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225400000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation Practitioner",
            "state": "CA",
            "license": "17771",
            "primary": true
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "CA",
            "license": "17771",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Rehabilitation Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.