Provider Demographics
NPI:1255452066
Name:NELSON, GUY ROGER (DC)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:ROGER
Last Name:NELSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-5802
Mailing Address - Country:US
Mailing Address - Phone:310-830-5616
Mailing Address - Fax:310-830-5617
Practice Address - Street 1:310 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5802
Practice Address - Country:US
Practice Address - Phone:310-830-5616
Practice Address - Fax:310-830-5617
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24182111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC24182Medicare UPIN