Provider Demographics
NPI:1275267692
Name:NELSON, BRADLEY JON (LDO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JON
Last Name:NELSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-0164
Mailing Address - Country:US
Mailing Address - Phone:828-899-0880
Mailing Address - Fax:
Practice Address - Street 1:141 DORMAN CENTRE DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2625
Practice Address - Country:US
Practice Address - Phone:828-574-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician