Provider Demographics
NPI:1932698099
Name:NELSON, BENJAMIN (DC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 OAK LEA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-8565
Mailing Address - Country:US
Mailing Address - Phone:217-825-5355
Mailing Address - Fax:
Practice Address - Street 1:250 PALM COAST PKWY NE UNIT 504
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8288
Practice Address - Country:US
Practice Address - Phone:386-225-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty