Healthcare Provider Details

I. General information

NPI: 1376962225
Provider Name (Legal Business Name): ROY WHITEEAGLE L.A.D.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 SILVER AVE SE SUITE F
ALBUQUERQUE NM
87108-2748
US

IV. Provider business mailing address

4300 SILVER AVE SE SUITE F
ALBUQUERQUE NM
87108-2748
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-1804
  • Fax: 505-265-4446
Mailing address:
  • Phone: 505-255-1804
  • Fax: 505-265-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number05998
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: