Provider Demographics
NPI:1891965562
Name:BRUCE D NELSON
Entity Type:Organization
Organization Name:BRUCE D NELSON
Other - Org Name:PELICAN RIVER OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-847-5663
Mailing Address - Street 1:1131 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3618
Mailing Address - Country:US
Mailing Address - Phone:218-847-5663
Mailing Address - Fax:218-847-0964
Practice Address - Street 1:1131 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3618
Practice Address - Country:US
Practice Address - Phone:218-847-5663
Practice Address - Fax:218-847-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0181390001Medicare NSC