MEDICARE: RIO GRANDE ALCOHOLISM TREATMENT PROGRAM

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	251S00000X	Community/Behavioral Health Agency	1754	NM
2	251S00000X	Community/Behavioral Health Agency	101YA0400X	NM

General Provider Information

NPI Number	:	1992140305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIO GRANDE ALCOHOLISM TREATMENT PROGRAM

Provider Business Mailing Address
First Line	:	2301 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4966
Country	:	US
Telephone Number	:	505-579-4253
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4966
Country	:	US
Telephone Number	:	505-579-4253
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. LAWRENCE A MEDINA
Credential	:	MBA
Telephone Number	:	505-579-4253

Provider Enumeration Date	:	04/30/2013
Last Update Date	:	04/30/2013

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