Healthcare Provider Details

I. General information

NPI: 1255764262
Provider Name (Legal Business Name): LARRY HERRERA LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 CRUZ ALTA ROAD
TAOS NM
87571
US

IV. Provider business mailing address

224 CRUZ ALTA RD
TAOS NM
87571-5947
US

V. Phone/Fax

Practice location:
  • Phone: 575-737-5533
  • Fax: 575-737-5534
Mailing address:
  • Phone: 575-737-5533
  • Fax: 575-737-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0161971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: