MEDICARE: SAMUEL NELSON III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1134678501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL NELSON III

Provider Business Mailing Address
First Line	:	1600 S VALLEY VIEW BLVD
Second Line	:	APT 2126
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1869
Country	:	US
Telephone Number	:	907-299-8760
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 S VALLEY VIEW BLVD
Second Line	:	APT 2126
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1869
Country	:	US
Telephone Number	:	907-299-8760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/27/2016

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