Provider Demographics
NPI:1538130158
Name:NELSON & ENDICOTT AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:NELSON & ENDICOTT AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-961-0877
Mailing Address - Street 1:15909 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-4720
Mailing Address - Country:US
Mailing Address - Phone:626-961-0877
Mailing Address - Fax:909-468-4603
Practice Address - Street 1:15909 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-4720
Practice Address - Country:US
Practice Address - Phone:626-961-0877
Practice Address - Fax:909-468-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6093T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001241Medicaid
CAGSD001241Medicaid
CAT87313Medicare UPIN