Healthcare Provider Details

I. General information

NPI: 1225385685
Provider Name (Legal Business Name): DAVID WILLIAM MAESTAS LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID WILLIAM MAESTAS CADAC

II. Dates (important events)

Enumeration Date: 08/04/2012
Last Update Date: 08/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 VIRGINIA ST NE STE 200
ALBUQUERQUE NM
87110-4689
US

IV. Provider business mailing address

713 MCKNIGHT AVE NW
ALBUQUERQUE NM
87102-1238
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-4449
  • Fax: 505-296-0497
Mailing address:
  • Phone: 505-304-7420
  • Fax: 505-200-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1028971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: