MEDICARE: DIXIE A. FULLERTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609923242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIXIE A. FULLERTON

Provider Business Mailing Address
First Line	:	1621 FREMONT ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-5413
Country	:	US
Telephone Number	:	702-382-8287
Fax Number	:	702-388-0727

Provider Business Practice Location Address
First Line	:	1621 FREMONT ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-5413
Country	:	US
Telephone Number	:	702-382-8287
Fax Number	:	702-388-0727

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DIXIE A FULLERTON
Credential	:
Telephone Number	:	702-382-8287

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/23/2012

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