Healthcare Provider Details

I. General information

NPI: 1114589645
Provider Name (Legal Business Name): PRIMA ELEMENTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 07/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 ANDERSON ST
FAYETTEVILLE NC
28301-5014
US

IV. Provider business mailing address

124 ANDERSON ST
FAYETTEVILLE NC
28301-5014
US

V. Phone/Fax

Practice location:
  • Phone: 910-483-8406
  • Fax:
Mailing address:
  • Phone: 910-483-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: ADRIAN RAMON BURGOS
Title or Position: CO-OWNER/MANAGER
Credential:
Phone: 910-483-8406