Provider Demographics
NPI:1083459630
Name:NELSON, SCOTT ANDREW (RD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:NELSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:MR
Other - First Name:SCOTT
Other - Middle Name:ANDREW
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:230 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1070
Mailing Address - Country:US
Mailing Address - Phone:734-658-2634
Mailing Address - Fax:
Practice Address - Street 1:230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1070
Practice Address - Country:US
Practice Address - Phone:734-658-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1073385133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered