Healthcare Provider Details

I. General information

NPI: 1215670856
Provider Name (Legal Business Name): LEONEL ZUNIGA LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 TOWN SQUARE LN
FARIBAULT MN
55021-6088
US

IV. Provider business mailing address

1415 TOWN SQUARE LN
FARIBAULT MN
55021-6088
US

V. Phone/Fax

Practice location:
  • Phone: 507-646-8970
  • Fax: 833-974-2090
Mailing address:
  • Phone: 507-646-8970
  • Fax: 833-974-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302162
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: