MEDICARE: MARIETTA NELSON CHTD

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	207W00000X	Ophthalmology Physician	5471	NV

General Provider Information

NPI Number	:	1952760480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIETTA NELSON CHTD

Provider Business Mailing Address
First Line	:	3100 W CHARLESTON BLVD STE 204
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1996
Country	:	US
Telephone Number	:	702-384-2020
Fax Number	:	702-384-6371

Provider Business Practice Location Address
First Line	:	3100 W CHARLESTON BLVD STE 204
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1996
Country	:	US
Telephone Number	:	702-384-2020
Fax Number	:	702-384-6371

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. NELSON NERVEZA LOPEZ
Credential	:	DO
Telephone Number	:	702-384-2020

Provider Enumeration Date	:	02/11/2016
Last Update Date	:	02/11/2016

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