Provider Demographics
NPI:1407328149
Name:PADILLA, ANTHONY RAY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAY
Last Name:PADILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LOS LENTES RD SE STE 3
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6018
Mailing Address - Country:US
Mailing Address - Phone:505-865-3350
Mailing Address - Fax:
Practice Address - Street 1:428 LOS LENTES RD SE STE 3
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6018
Practice Address - Country:US
Practice Address - Phone:505-865-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator