Provider Demographics
NPI:1760149702
Name:NELSON, KELVIN
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:NELSON
Suffix:
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 1:47915 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6950
Mailing Address - Country:US
Mailing Address - Phone:760-863-8632
Mailing Address - Fax:
Practice Address - Street 1:3446 SISKIYOU CIR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4664
Practice Address - Country:US
Practice Address - Phone:951-833-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA787093163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty