Healthcare Provider Details

I. General information

NPI: 1760149702
Provider Name (Legal Business Name): KELVIN NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 SISKIYOU CIR
RIVERSIDE CA
92503-4664
US

IV. Provider business mailing address

47915 OASIS ST
INDIO CA
92201-6950
US

V. Phone/Fax

Practice location:
  • Phone: 951-833-5050
  • Fax:
Mailing address:
  • Phone: 760-863-8632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number787093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: