Healthcare Provider Details

I. General information

NPI: 1508366964
Provider Name (Legal Business Name): BRIAN NELSON LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MAIN ST STE 650
SANTA ANA CA
92701-3613
US

IV. Provider business mailing address

1200 N MAIN ST STE 650
SANTA ANA CA
92701-3613
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-8140
  • Fax: 714-824-8142
Mailing address:
  • Phone: 714-824-8140
  • Fax: 714-824-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN253162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: