MEDICARE: THE RIVER SOURCE OUTPATIENT TUSCON

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	CSLG7586	AZ

General Provider Information

NPI Number	:	1023471760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE RIVER SOURCE OUTPATIENT TUSCON

Provider Business Mailing Address
First Line	:	6700 N ORACLE ROAD
Second Line	:	SUITE 121
City	:	TUSCSON
State	:	AZ
Zip	:	85704-7733
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6700 N ORACLE ROAD
Second Line	:	SUITE 121
City	:	TUSCSON
State	:	AZ
Zip	:	85704-7733
Country	:	US
Telephone Number	:	623-277-8385
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF ACCOUNT MANAGEMENT
Name	:	JOHN RICHARDS
Credential	:
Telephone Number	:	561-413-9860

Provider Enumeration Date	:	03/31/2016
Last Update Date	:	03/31/2016

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Directions to “THE RIVER SOURCE OUTPATIENT TUSCON ” Practice Location

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