Provider Demographics
NPI:1104223049
Name:BROWN, NELSON JR
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 BOULDER AVE
Mailing Address - Street 2:SUITE 293
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3313
Mailing Address - Country:US
Mailing Address - Phone:909-910-8200
Mailing Address - Fax:
Practice Address - Street 1:7231 BOULDER AVE
Practice Address - Street 2:SUITE 293
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3313
Practice Address - Country:US
Practice Address - Phone:909-910-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46246174400000X
174H00000X, 133NN1002X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No174400000XOther Service ProvidersSpecialist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist