Healthcare Provider Details

I. General information

NPI: 1033023171
Provider Name (Legal Business Name): ISRAEL MELTON LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W FRAZIER ST
CAMDEN TN
38320-1223
US

IV. Provider business mailing address

108 W FRAZIER ST
CAMDEN TN
38320-1223
US

V. Phone/Fax

Practice location:
  • Phone: 731-441-7432
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1179
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: