Healthcare Provider Details

I. General information

NPI: 1417685652
Provider Name (Legal Business Name): ZACHARY GENE PETRO LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2022
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 HAINES AVE NW
ALBUQUERQUE NM
87102-1226
US

IV. Provider business mailing address

630 HAINES AVE NW
ALBUQUERQUE NM
87102-1226
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5611
  • Fax: 505-268-5736
Mailing address:
  • Phone: 505-268-5611
  • Fax: 505-268-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0086
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: