Healthcare Provider Details

I. General information

NPI: 1609089408
Provider Name (Legal Business Name): UNA ALA CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LOS ALAMOS HWY
ESPANOLA NM
87532-2747
US

IV. Provider business mailing address

104 LOS ALAMOS HWY
ESPANOLA NM
87532-2747
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-8187
  • Fax: 505-747-8306
Mailing address:
  • Phone: 505-747-8187
  • Fax: 505-747-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberCSOOO2020217
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL MARTINEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-747-8187