=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104469766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES NELSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2019
-----------------------------------------------------
Last Update Date | 10/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 CENTERVILLE RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-633-4091
-----------------------------------------------------
Fax | 302-633-5680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 JERSEY CT
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19709-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-449-2085
-----------------------------------------------------
Fax | 302-449-2085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | U1-0000254
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------