Healthcare Provider Details

I. General information

NPI: 1417829482
Provider Name (Legal Business Name): JOSE CANDELARIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2025
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E BONNEY ST
ROSWELL NM
88203-5903
US

IV. Provider business mailing address

325 E BONNEY ST
ROSWELL NM
88203-5903
US

V. Phone/Fax

Practice location:
  • Phone: 432-703-3029
  • Fax:
Mailing address:
  • Phone: 432-703-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: