Healthcare Provider Details

I. General information

NPI: 1942510748
Provider Name (Legal Business Name): WILLIAM FRESQUEZ LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 STATE HWY 518 HELPING HANDS INC
MORA NM
87732-0708
US

IV. Provider business mailing address

HWY 121 #595 P.O. BOX 72
CHACON NM
87713-0072
US

V. Phone/Fax

Practice location:
  • Phone: 575-387-2288
  • Fax:
Mailing address:
  • Phone: 575-387-2764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3718
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: