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816 Highway 22 Pena Blanca NM 87041 | |
| (505) 470-2887 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor - Addiction (substance Use Disorder) |
| Location | 816 Highway 22, Pena Blanca, New Mexico |
| Authorized Official Name and Position | Lawrence A Medina (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5054702887 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1270 Pena Blanca NM 87041-1270 Ph: () - | 816 Highway 22 Pena Blanca NM 87041 Ph: (505) 470-2887 |
| NPI Number | 1770960064 |
|---|---|
| Provider Enumeration Date | 05/06/2015 |
| Last Update Date | 07/20/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1770960064 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |