MEDICARE: NEW RIVER SERVICE AUTHORITY

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	MHL-059-050	NC

General Provider Information

NPI Number	:	1205132008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW RIVER SERVICE AUTHORITY

Provider Business Mailing Address
First Line	:	895 STATE FARM RD
Second Line	:	SUITE 508
City	:	BOONE
State	:	NC
Zip	:	28607-4917
Country	:	US
Telephone Number	:	828-263-5666
Fax Number	:	828-262-5687

Provider Business Practice Location Address
First Line	:	172 LUKIN ST
Second Line	:
City	:	MARION
State	:	NC
Zip	:	28752-5245
Country	:	US
Telephone Number	:	828-263-5666
Fax Number	:	828-262-5687

Authorized Official
Title or Position	:	PROVIDER PANEL MANAGER
Name	:	DONNA G BUCHANAN
Credential	:
Telephone Number	:	828-263-5666

Provider Enumeration Date	:	01/27/2011
Last Update Date	:	01/27/2011

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Directions to “NEW RIVER SERVICE AUTHORITY ” Practice Location

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