Healthcare Provider Details

I. General information

NPI: 1144740903
Provider Name (Legal Business Name): CARLOS GONZALES LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SAINT MICHAELS DR STE 5
SANTA FE NM
87505-7630
US

IV. Provider business mailing address

PO BOX 4144
SANTA FE NM
87502-4144
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-3488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0189851
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: