MEDICARE: LIFESTYLE RECOVERY INC.

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	02-491408-00-8	NM

General Provider Information

NPI Number	:	1891962510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE RECOVERY INC.

Provider Business Mailing Address
First Line	:	3911 4TH ST NW STE B
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-2510
Country	:	US
Telephone Number	:	505-345-6801
Fax Number	:

Provider Business Practice Location Address
First Line	:	3911 4TH ST NW STE B
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-2510
Country	:	US
Telephone Number	:	505-345-6801
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	MR. MATTHEW JAMES REILLY
Credential	:	LADAC NM #3652
Telephone Number	:	505-345-6801

Provider Enumeration Date	:	05/12/2008
Last Update Date	:	05/12/2008

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