Healthcare Provider Details

I. General information

NPI: 1083735997
Provider Name (Legal Business Name): MARK SANCHEZ LADAC,LCDC,ICADC,CAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BROADWAY STE D
FARMINGTON NM
87401-5638
US

IV. Provider business mailing address

PO BOX 2707
SHIPROCK NM
87420-2707
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-0238
  • Fax: 505-327-7247
Mailing address:
  • Phone: 505-368-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0084741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: