=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003118886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMELIA NELSON BS PT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2010
-----------------------------------------------------
Last Update Date | 11/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1869 GREENTREE RD
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08003-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-424-2444
-----------------------------------------------------
Fax | 856-424-8632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1869 GREENTREE RD
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08003-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-424-2444
-----------------------------------------------------
Fax | 856-424-8632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | AMELIA NELSON
-----------------------------------------------------
Credential | BS, PT, CCTT
-----------------------------------------------------
Telephone | 856-424-2444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QA00242000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------