Healthcare Provider Details

I. General information

NPI: 1275867772
Provider Name (Legal Business Name): ZANE ROMANCITO LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 D AVE BLACK ROCK
ZUNI NM
87327
US

IV. Provider business mailing address

PO BOX 339 C/O ZUNI RECOVERY CENTER
ZUNI NM
87327-0339
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-4710
  • Fax: 505-782-5880
Mailing address:
  • Phone: 505-782-4710
  • Fax: 505-782-5880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number005837
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: