MEDICARE: THE OLIVE BRANCH RECOVERY SERVICES 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1912839267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE OLIVE BRANCH RECOVERY SERVICES LLC

Provider Business Mailing Address
First Line	:	1820 MESA GRANDE LOOP NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-0567
Country	:	US
Telephone Number	:	505-484-0406
Fax Number	:	505-484-0406

Provider Business Practice Location Address
First Line	:	1820 MESA GRANDE LOOP NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-0567
Country	:	US
Telephone Number	:	505-484-0406
Fax Number	:	505-484-0406

Authorized Official
Title or Position	:	OWNER
Name	:	LORRISSA L SHORT
Credential	:	LADAC, CCSS, CPSW
Telephone Number	:	505-484-0406

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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