MEDICARE: DISMAS HOUSE NM INC.

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	324500000X	Substance Abuse Rehabilitation Facility		NM

General Provider Information

NPI Number	:	1386870137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISMAS HOUSE NM INC.

Provider Business Mailing Address
First Line	:	PO BOX 6101
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87197-6101
Country	:	US
Telephone Number	:	505-343-0746
Fax Number	:	505-345-4513

Provider Business Practice Location Address
First Line	:	701 CANDELARIA RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-2407
Country	:	US
Telephone Number	:	505-343-0746
Fax Number	:	505-345-4513

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RUSTY SMITH
Credential	:	REVEREND
Telephone Number	:	505-343-0746

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	06/08/2009

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Directions to “DISMAS HOUSE NM INC. ” Practice Location

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