MEDICARE: MICHAEL NELL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	2624T	TX
2	152WL0500X	Low Vision Rehabilitation Optometrist	2624T	TX
3	152WP0200X	Pediatric Optometrist	2624T	TX
4	152WS0006X	Sports Vision Optometrist	2624T	TX
5	152WV0400X	Vision Therapy Optometrist	2624T	TX
6	152WX0102X	Occupational Vision Optometrist	2624T	TX
7	152W00000X	Optometrist	2624T	TX

General Provider Information

NPI Number	:	1174968002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL NELL PC

Provider Business Mailing Address
First Line	:	1148 W DALLAS ST
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77301-2208
Country	:	US
Telephone Number	:	936-756-8612
Fax Number	:

Provider Business Practice Location Address
First Line	:	1148 W DALLAS ST
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77301-2208
Country	:	US
Telephone Number	:	936-756-8612
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICAEL NELL
Credential	:	O.D.
Telephone Number	:	936-756-8612

Provider Enumeration Date	:	05/06/2013
Last Update Date	:	05/03/2016

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