Healthcare Provider Details

I. General information

NPI: 1437137429
Provider Name (Legal Business Name): RICHARD LOREN NELSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N JEFFERSON WAY
INDIANOLA IA
50125-1465
US

IV. Provider business mailing address

12817 FORD TRL S
INDIANOLA IA
50125-8930
US

V. Phone/Fax

Practice location:
  • Phone: 515-961-7573
  • Fax: 515-961-7586
Mailing address:
  • Phone: 515-961-7573
  • Fax: 515-961-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number01595
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: