Healthcare Provider Details

I. General information

NPI: 1063921831
Provider Name (Legal Business Name): DAVID SEGURA LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 4TH AVE
RATON NM
87740-2643
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-4072
  • Fax:
Mailing address:
  • Phone: 505-384-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4000
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: