Provider Demographics
NPI:1194924928
Name:RIO GRANDE ALCOHOLISM TREATMENT CENTER INCORPORATED
Entity type:Organization
Organization Name:RIO GRANDE ALCOHOLISM TREATMENT CENTER INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-737-5533
Mailing Address - Street 1:105 PASEO DEL CANON W STE A
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6943
Mailing Address - Country:US
Mailing Address - Phone:575-737-5533
Mailing Address - Fax:575-737-5534
Practice Address - Street 1:105 PASEO DEL CANON W STE A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6943
Practice Address - Country:US
Practice Address - Phone:575-737-5533
Practice Address - Fax:575-737-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2025-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5517324500000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83774556Medicaid