=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881031417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDDISON NELSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2013
-----------------------------------------------------
Last Update Date | 05/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1292 DORCHESTER ST
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-623-2267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1292 DORCHESTER ST
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EDDISON NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-623-2267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906576
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------