Provider Demographics
NPI:1912559535
Name:NELSON, ALEX JACE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JACE
Last Name:NELSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 REGISTER CT
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-7950
Mailing Address - Country:US
Mailing Address - Phone:509-599-0332
Mailing Address - Fax:
Practice Address - Street 1:309 S MEDFORD DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-5245
Practice Address - Country:US
Practice Address - Phone:936-632-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT71062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer