Provider Demographics
NPI:1558644161
Name:RIO GRANDE ALCOHOLISM TREATMENT PROGRAM, INC.
Entity Type:Organization
Organization Name:RIO GRANDE ALCOHOLISM TREATMENT PROGRAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:505-579-4253
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:EMBUDO
Mailing Address - State:NM
Mailing Address - Zip Code:87531-0310
Mailing Address - Country:US
Mailing Address - Phone:505-579-4253
Mailing Address - Fax:
Practice Address - Street 1:225 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3832
Practice Address - Country:US
Practice Address - Phone:505-454-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YA0400X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health