Healthcare Provider Details

I. General information

NPI: 1376093138
Provider Name (Legal Business Name): EDDEANA UELAND L.A.D.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 32ND STREET BYP
SILVER CITY NM
88061-7802
US

IV. Provider business mailing address

530 DE MOSS ST
LORDSBURG NM
88045-2617
US

V. Phone/Fax

Practice location:
  • Phone: 575-597-2265
  • Fax: 575-597-2651
Mailing address:
  • Phone: 575-572-8384
  • Fax: 575-597-2651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4110
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0105891
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: