MEDICARE: MARY NEL TWO, LLC

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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1174891857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY NEL TWO, LLC

Provider Business Mailing Address
First Line	:	2505 W PLUM STREET
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3144
Country	:	US
Telephone Number	:	970-412-6394
Fax Number	:	970-663-3227

Provider Business Practice Location Address
First Line	:	2505 W PLUM ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3144
Country	:	US
Telephone Number	:	970-412-6394
Fax Number	:	970-663-3227

Authorized Official
Title or Position	:	OWNER
Name	:	MARY L NEL
Credential	:	MS,CCC/SLP
Telephone Number	:	970-412-6394

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	12/08/2011

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