Provider Demographics
NPI:1871659284
Name:NELSON, BRAD LESTER (ATC-L)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:LESTER
Last Name:NELSON
Suffix:
Gender:M
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4865 HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-7966
Mailing Address - Country:US
Mailing Address - Phone:435-245-0478
Mailing Address - Fax:
Practice Address - Street 1:162 W 100 S
Practice Address - Street 2:LOGAN HIGH SCHOOL
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5229
Practice Address - Country:US
Practice Address - Phone:435-755-2380
Practice Address - Fax:435-755-2387
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2378103-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer