Healthcare Provider Details

I. General information

NPI: 1235538307
Provider Name (Legal Business Name): CLEMENTE SALAZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

IV. Provider business mailing address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-852-2580
  • Fax: 505-852-1827
Mailing address:
  • Phone: 505-852-2580
  • Fax: 505-852-1827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3725
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: