MEDICARE: MR. ROBERT L NELSON JR. CACIII

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	4054	CO

General Provider Information

NPI Number	:	1659501013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT L NELSON JR. CACIII

Provider Business Mailing Address
First Line	:	107 ACOMA ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80223-1429
Country	:	US
Telephone Number	:	303-722-5746
Fax Number	:	303-777-7601

Provider Business Practice Location Address
First Line	:	107 ACOMA ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80223-1429
Country	:	US
Telephone Number	:	303-722-5746
Fax Number	:	303-777-7601

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

Provider Enumeration Date	:	07/20/2009
Last Update Date	:	07/20/2009

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