Healthcare Provider Details

I. General information

NPI: 1124756267
Provider Name (Legal Business Name): TYRONE JON KAY LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W NIZHONI BLVD STE A
GALLUP NM
87301-5766
US

IV. Provider business mailing address

300 W NIZHONI BLVD STE A
GALLUP NM
87301-5766
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-9470
  • Fax: 505-722-9570
Mailing address:
  • Phone: 505-722-9470
  • Fax: 505-722-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0225331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: