Healthcare Provider Details

I. General information

NPI: 1376841791
Provider Name (Legal Business Name): CHARLES E CARTER LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 GOLF COURSE RD SE SUITE A
RIO RANCHO NM
87124-1762
US

IV. Provider business mailing address

1603 GOLF COURSE RD SE SUITE A
RIO RANCHO NM
87124-1762
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-4100
  • Fax: 505-994-1229
Mailing address:
  • Phone: 505-994-4100
  • Fax: 505-994-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3701
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: