1841621307 NPI number — ELVIRA THERESA NELSON CERT. HAIR LOSS SPEC

Table of content: ELVIRA THERESA NELSON CERT. HAIR LOSS SPEC (NPI 1841621307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841621307 NPI number — ELVIRA THERESA NELSON CERT. HAIR LOSS SPEC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
ELVIRA
Provider Middle Name:
THERESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERT. HAIR LOSS SPEC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841621307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 CAMP GROUND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29203-9442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-210-7669
Provider Business Mailing Address Fax Number:
803-333-9831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 BUSH RIVER RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-7332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-731-1020
Provider Business Practice Location Address Fax Number:
803-333-9831
Provider Enumeration Date:
12/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1744P3200X , with the licence number:  10401 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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