Healthcare Provider Details

I. General information

NPI: 1780894030
Provider Name (Legal Business Name): CARL J REGENSBERG LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 YALE BLVD SE
ALBUQUERQUE NM
87106-4228
US

IV. Provider business mailing address

2701 COCONO DR SW
ALBUQUERQUE NM
87105-7089
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4622
  • Fax: 505-247-1373
Mailing address:
  • Phone: 505-873-1935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3676
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: