Healthcare Provider Details

I. General information

NPI: 1912934803
Provider Name (Legal Business Name): RICHARD A NELSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 HARRISON ROAD WAL-MART VISION CENTER
THOMSON GA
30824
US

IV. Provider business mailing address

PO BOX 5721 ATTN: ADMINISTRATOR
COLUMBIA SC
29250
US

V. Phone/Fax

Practice location:
  • Phone: 706-595-9534
  • Fax: 706-595-6512
Mailing address:
  • Phone: 803-779-2273
  • Fax: 803-799-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1032
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001682
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: