Provider Demographics
NPI:1609923242
Name:DIXIE A. FULLERTON
Entity Type:Organization
Organization Name:DIXIE A. FULLERTON
Other - Org Name:SUPERIOR LIMB & BRACE COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-382-8287
Mailing Address - Street 1:1621 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-5413
Mailing Address - Country:US
Mailing Address - Phone:702-382-8287
Mailing Address - Fax:702-388-0727
Practice Address - Street 1:1621 FREMONT ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-5413
Practice Address - Country:US
Practice Address - Phone:702-382-8287
Practice Address - Fax:702-388-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003302875Medicaid
NV003302875Medicaid