Provider Demographics
NPI:1417829482
Name:CANDELARIA, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CANDELARIA
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 1:325 E BONNEY ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5903
Mailing Address - Country:US
Mailing Address - Phone:432-703-3029
Mailing Address - Fax:
Practice Address - Street 1:325 E BONNEY ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5903
Practice Address - Country:US
Practice Address - Phone:432-703-3029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty