MEDICARE: MR. MICJHAEL PATRICK O'MALLEY LADAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LADAC3619	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LADAC3619	OTHER	NM	LICENSE NUMBER

General Provider Information

NPI Number	:	1710205596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICJHAEL PATRICK O'MALLEY LADAC

Provider Business Mailing Address
First Line	:	PO BOX 373
Second Line	:
City	:	RADIUM SPRINGS
State	:	NM
Zip	:	88054-0373
Country	:	US
Telephone Number	:	575-621-9660
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 E IDAHO AVE
Second Line	:	4B
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-4703
Country	:	US
Telephone Number	:	575-524-2505
Fax Number	:	575-524-2504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	05/04/2010

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Directions to “ MR. MICJHAEL PATRICK O'MALLEY LADAC” Practice Location

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