Healthcare Provider Details

I. General information

NPI: 1134526460
Provider Name (Legal Business Name): BOB NELSON BMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E SANTA FE AVE SUITE A
GRANTS NM
87020-2443
US

IV. Provider business mailing address

2551 COORS BLVD NW
ALBUQUERQUE NM
87120-1213
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-1890
  • Fax:
Mailing address:
  • Phone: 505-338-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: