Healthcare Provider Details

I. General information

NPI: 1861686511
Provider Name (Legal Business Name): JOHN STAN ESPINOZA LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU ROAD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1214
TAOS NM
87571-1214
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-5857
  • Fax:
Mailing address:
  • Phone: 505-737-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0073521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: