Provider Demographics
NPI:1053480012
Name:NELSON FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:NELSON FAMILY CLINIC LLC
Other - Org Name:NELSON FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:E
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C,PHD
Authorized Official - Phone:920-853-3444
Mailing Address - Street 1:308 W MAIN ST
Mailing Address - Street 2:PO BOX 202
Mailing Address - City:HILBERT
Mailing Address - State:WI
Mailing Address - Zip Code:54129-9282
Mailing Address - Country:US
Mailing Address - Phone:920-853-3444
Mailing Address - Fax:920-853-3550
Practice Address - Street 1:308 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:HILBERT
Practice Address - State:WI
Practice Address - Zip Code:54129-0202
Practice Address - Country:US
Practice Address - Phone:920-853-3444
Practice Address - Fax:920-853-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
556441261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43059900Medicaid
0000-10040Medicare PIN