Healthcare Provider Details

I. General information

NPI: 1083613830
Provider Name (Legal Business Name): DALE E NELSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 GREELEY AVE N
GLENCOE MN
55336-2103
US

IV. Provider business mailing address

4690 W ARM RD
SPRING PARK MN
55384-9703
US

V. Phone/Fax

Practice location:
  • Phone: 320-864-6111
  • Fax: 320-864-6134
Mailing address:
  • Phone: 952-471-0562
  • Fax: 888-770-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1525
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: