Basic Information
| Provider Information | |||||||||
| NPI: | 1104024199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLORES | ||||||||
| FirstName: | NICOLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6621 DONIPHAN DR STE G | ||||||||
| Address2: | |||||||||
| City: | CANUTILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 798355005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158775100 | ||||||||
| FaxNumber: | 9158775107 | ||||||||
| Practice Location | |||||||||
| Address1: | 6621 DONIPHAN DR STE G | ||||||||
| Address2: | |||||||||
| City: | CANUTILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 798355005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158775100 | ||||||||
| FaxNumber: | 9158775107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3620 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | VNM30451NI | 05 | NM | MEDICAID |