Provider Demographics
NPI:1700636701
Name:NELSON, BRENT RICHARD
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:RICHARD
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:PO BOX 1114
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0534
Mailing Address - Country:US
Mailing Address - Phone:503-507-8710
Mailing Address - Fax:
Practice Address - Street 1:1106 S COMMERCIAL WAY SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-7034
Practice Address - Country:US
Practice Address - Phone:503-507-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR078408225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist