Healthcare Provider Details

I. General information

NPI: 1598295149
Provider Name (Legal Business Name): BENJAMIN GRANT NIELSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

IV. Provider business mailing address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

V. Phone/Fax

Practice location:
  • Phone: 509-324-6464
  • Fax:
Mailing address:
  • Phone: 509-324-6464
  • Fax: 509-241-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number100413
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number100413
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number100413
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number100413
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number100413
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number100413
License Number StateID
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number100413
License Number StateID
# 8
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60876418
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: