Provider Demographics
NPI:1164762191
Name:PRIMEAUX, BRIAN C
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:PRIMEAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 BUNCOMBE RD
Mailing Address - Street 2:APT. 1011
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2697
Mailing Address - Country:US
Mailing Address - Phone:337-852-6386
Mailing Address - Fax:
Practice Address - Street 1:5610 BUNCOMBE RD
Practice Address - Street 2:APT. 1011
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2697
Practice Address - Country:US
Practice Address - Phone:337-852-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46416390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program