Basic Information
| Provider Information | |||||||||
| NPI: | 1376604561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIMER | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1332 ELLIOTT RD | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308774371 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2858 OLIVE HIGHWAY | ||||||||
| Address2: | SUITES A B & C | ||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305382158 | ||||||||
| FaxNumber: | 5305337188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | X | Behavioral Health & Social Service Providers | Psychologist | School | 171M00000X | X | Other Service Providers | Case Manager/Care Coordinator | 225C00000X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
ID Information
| ID | Type | State | Issuer | Description | A3850502 | 01 | CA | CAADAC | OTHER |