Healthcare Provider Details

I. General information

NPI: 1053702548
Provider Name (Legal Business Name): YEVGENI BALICEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3600
US

IV. Provider business mailing address

PO BOX 158 EL CENTRO FAMILY HEALTH
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7395
  • Fax: 505-753-8373
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08056
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-08056
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: