Healthcare Provider Details

I. General information

NPI: 1518291558
Provider Name (Legal Business Name): MARK MARTINEZ LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 'D' AVENUE BLACK ROCK
ZUNI NM
87327-0101
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 Number006263
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: