MEDICARE: RIVERS IN THE DESERT EYE CLINIC

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	305S00000X	Point of Service	NM399	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124391768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERS IN THE DESERT EYE CLINIC

Provider Business Mailing Address
First Line	:	306 S LAKE ST
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5620
Country	:	US
Telephone Number	:	505-326-0552
Fax Number	:	505-326-0552

Provider Business Practice Location Address
First Line	:	306 S LAKE ST
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5620
Country	:	US
Telephone Number	:	505-326-0552
Fax Number	:	505-326-0552

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	BOBBIE DELABARCENA
Credential	:
Telephone Number	:	505-326-0552

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	02/13/2012

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