Provider Demographics
NPI:1114274800
Name:KEVIN R. NELSON, O.D., P.C.
Entity Type:Organization
Organization Name:KEVIN R. NELSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:REED
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-352-9141
Mailing Address - Street 1:228 BELLOWS AVE
Mailing Address - Street 2:P.O. BOX 2158
Mailing Address - City:FRANKFORT
Mailing Address - State:MI
Mailing Address - Zip Code:49635-9055
Mailing Address - Country:US
Mailing Address - Phone:231-352-9141
Mailing Address - Fax:231-352-9739
Practice Address - Street 1:228 BELLOWS AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:MI
Practice Address - Zip Code:49635-9055
Practice Address - Country:US
Practice Address - Phone:231-352-9141
Practice Address - Fax:231-352-9739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002866302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5872Medicare PIN