Basic Information
| Provider Information | |||||||||
| NPI: | 1710210513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIM | ||||||||
| FirstName: | LORENZO | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052622481 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Practice Location | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052622481 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0125371 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0125371 | 01 | NM | STATE LICENSE | OTHER |