Healthcare Provider Details

I. General information

NPI: 1912839267
Provider Name (Legal Business Name): THE OLIVE BRANCH RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 MESA GRANDE LOOP NE
RIO RANCHO NM
87144-0567
US

IV. Provider business mailing address

1820 MESA GRANDE LOOP NE
RIO RANCHO NM
87144-0567
US

V. Phone/Fax

Practice location:
  • Phone: 505-484-0406
  • Fax: 505-484-0406
Mailing address:
  • Phone: 505-484-0406
  • Fax: 505-484-0406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LORRISSA L SHORT
Title or Position: OWNER
Credential: LADAC, CCSS, CPSW
Phone: 505-484-0406