Healthcare Provider Details

I. General information

NPI: 1487015186
Provider Name (Legal Business Name): DIXIE BINGHAM III LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

IV. Provider business mailing address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6919
  • Fax: 505-242-6929
Mailing address:
  • Phone: 505-242-6919
  • Fax: 505-242-6929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0131151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: