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General NPI Number Information
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NPI Number | 1285736355
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Entity Type | Organization
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Legal Business Name | NELSON NELSON NELSON OD INC
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Dates
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Enumeration Date | 09/01/2006
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Last Update Date | 02/11/2014
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Provider Practice Location Address
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Address Line | 203 N NOBLE AVE
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City | WATONGA
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State | OK
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Zip | 73772-0590
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Country | US
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Telephone | 580-623-5073
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Fax | 580-623-5020
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Provider Business Mailing Address
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Address Line | 203 N NOBLE AVE
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City | WATONGA
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State | OK
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Zip | 73772-0590
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Country | US
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Telephone | 580-623-5073
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Fax | 580-623-5020
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY LAYNE NELSON
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Credential | OD
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Telephone | 580-623-5073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 1011
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1011
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License Number State | OK
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