Provider Demographics
NPI:1750880670
Name:NELSON, RICHARD JR
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:NELSON
Suffix:JR
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 1:883 CAVAN DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-8344
Mailing Address - Country:US
Mailing Address - Phone:407-948-5689
Mailing Address - Fax:
Practice Address - Street 1:6239 EDGEWATER DR STE 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-4736
Practice Address - Country:US
Practice Address - Phone:407-948-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver