Provider Demographics
NPI:1972390698
Name:PRINCE, ELIJAH KENNETH
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:KENNETH
Last Name:PRINCE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 VISTA DEL SOL DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3299
Mailing Address - Country:US
Mailing Address - Phone:760-815-0568
Mailing Address - Fax:
Practice Address - Street 1:6800 VISTA DEL SOL DR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3299
Practice Address - Country:US
Practice Address - Phone:760-815-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services