Provider Demographics
NPI:1497957740
Name:MICHAEL S. NELSON
Entity Type:Organization
Organization Name:MICHAEL S. NELSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-4440
Mailing Address - Street 1:605 EUREKA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-3839
Mailing Address - Country:US
Mailing Address - Phone:870-423-4042
Mailing Address - Fax:870-423-7173
Practice Address - Street 1:605 EUREKA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3839
Practice Address - Country:US
Practice Address - Phone:870-423-4042
Practice Address - Fax:870-423-7173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1932119054OtherNPI #