Healthcare Provider Details

I. General information

NPI: 1255598108
Provider Name (Legal Business Name): KENNY D SANCHEZ L. A. D. A. C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 VANDEN BOSCH PKWY
GALLUP NM
87301-5508
US

IV. Provider business mailing address

650 VANDEN BOSCH PKWY
GALLUP NM
87301-5508
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-6931
  • Fax: 505-722-5862
Mailing address:
  • Phone: 505-726-6931
  • Fax: 505-722-5862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0066982
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: