Basic Information
Provider Information
NPI: 1003018623
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SALAZAR
FirstName: RAYMOND
MiddleName: MOSES
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2265 LAVA LN
Address2:  
City: ALAMOSA
State: CO
PostalCode: 811013578
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2265 LAVA LN
Address2:  
City: ALAMOSA
State: CO
PostalCode: 811013578
CountryCode: US
TelephoneNumber: 7195895176
FaxNumber: 7195895795
Other Information
ProviderEnumerationDate: 06/05/2007
LastUpdateDate: 02/11/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X5630COY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YA0400X CON Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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