Healthcare Provider Details

I. General information

NPI: 1710772249
Provider Name (Legal Business Name): DONALD TYLER III LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 GOLF COURSE RD SE
RIO RANCHO NM
87124-1763
US

IV. Provider business mailing address

1712 GOLF COURSE RD SE
RIO RANCHO NM
87124-1763
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-7103
  • Fax:
Mailing address:
  • Phone: 505-850-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0663
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: