MEDICARE: EATING DISORDERS TREATMENT CENTER, LLC

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	1291	NM

General Provider Information

NPI Number	:	1871881326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EATING DISORDERS TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	5203 JUAN TABO BLVD NE
Second Line	:	SUITE 2-B
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2683
Country	:	US
Telephone Number	:	505-266-6121
Fax Number	:	505-271-1065

Provider Business Practice Location Address
First Line	:	5203 JUAN TABO BLVD NE
Second Line	:	SUITE 2-B
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2683
Country	:	US
Telephone Number	:	505-266-6121
Fax Number	:	505-271-1065

Authorized Official
Title or Position	:	DIRECTOR
Name	:	HOLLY ANN FINLAY
Credential	:	MA, LPCC, CEDS, CSP
Telephone Number	:	505-266-6121

Provider Enumeration Date	:	07/19/2011
Last Update Date	:	07/19/2011

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