Healthcare Provider Details

I. General information

NPI: 1750125357
Provider Name (Legal Business Name): NELSON MARQUES RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

944 S STADIUM DR
COLUMBIA SC
29208-4019
US

IV. Provider business mailing address

635 E EAU GALLIE BLVD
INDIAN HARBOUR BEACH FL
32937-4242
US

V. Phone/Fax

Practice location:
  • Phone: 201-388-4444
  • Fax:
Mailing address:
  • Phone: 201-388-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: