Healthcare Provider Details

I. General information

NPI: 1861329450
Provider Name (Legal Business Name): KEITH NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

119 HARVESTWOOD DR
GROVETOWN GA
30813-2154
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0211
  • Fax:
Mailing address:
  • Phone: 706-312-4865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: