Healthcare Provider Details

I. General information

NPI: 1659563609
Provider Name (Legal Business Name): CHARLES BACA LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 S SAINT FRANCIS DR
SANTA FE NM
87505-4037
US

IV. Provider business mailing address

617 JACKSON AVE APT B
GRANTS NM
87020-2908
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-2271
  • Fax: 505-982-0620
Mailing address:
  • Phone: 505-982-8870
  • Fax: 505-982-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0064141
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: