MEDICARE: JESSE L NELSON IRRV TR AGREEMENT

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1316211139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSE L NELSON IRRV TR AGREEMENT

Provider Business Mailing Address
First Line	:	2775 SUNNY ISLES BLVD STE 118
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-4078
Country	:	US
Telephone Number	:	786-489-2453
Fax Number	:

Provider Business Practice Location Address
First Line	:	2775 SUNNY ISLES BLVD STE 118
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-4078
Country	:	US
Telephone Number	:	786-489-2453
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF MKTG & BSA DEVELOPMENT
Name	:	MS. SHELLEY L. PATTERSON
Credential	:
Telephone Number	:	786-489-2453

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	03/27/2012

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