Healthcare Provider Details

I. General information

NPI: 1457093189
Provider Name (Legal Business Name): ADRIAN CARL EATON PSR CLASSROOM INST.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BROADWAY STE D&E
FARMINGTON NM
87401-5638
US

IV. Provider business mailing address

2800 N DUSTIN AVE APT 327
FARMINGTON NM
87401-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4796
  • Fax:
Mailing address:
  • Phone: 505-386-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: