Healthcare Provider Details

I. General information

NPI: 1194924928
Provider Name (Legal Business Name): RIO GRANDE ALCOHOLISM TREATMENT CENTER INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 03/09/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PASEO DEL CANON W STE A
TAOS NM
87571-6943
US

IV. Provider business mailing address

105 PASEO DEL CANON W STE A
TAOS NM
87571-6943
US

V. Phone/Fax

Practice location:
  • Phone: 575-737-5533
  • Fax: 575-737-5534
Mailing address:
  • Phone: 575-737-5533
  • Fax: 575-737-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number5517
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE MEDINA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-737-5533