Provider Demographics
NPI:1619216744
Name:PRIMUS, ELTRICK LORENZO
Entity Type:Individual
Prefix:
First Name:ELTRICK
Middle Name:LORENZO
Last Name:PRIMUS
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 1:2600 MARBLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2058
Mailing Address - Country:US
Mailing Address - Phone:505-272-2800
Mailing Address - Fax:
Practice Address - Street 1:2600 MARBLE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2058
Practice Address - Country:US
Practice Address - Phone:505-272-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX824845163W00000X
NM824845163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult