MEDICARE: BERNADINE JOANN MEDINA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	0107321	NM

General Provider Information

NPI Number	:	1255595302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNADINE JOANN MEDINA

Provider Business Mailing Address
First Line	:	PO BOX 2737
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-2737
Country	:	US
Telephone Number	:	505-425-6786
Fax Number	:	505-425-6787

Provider Business Practice Location Address
First Line	:	3001 HOTSPRINGS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-2737
Country	:	US
Telephone Number	:	505-425-6786
Fax Number	:	505-425-6787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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Directions to “ BERNADINE JOANN MEDINA ” Practice Location

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