1558644161 NPI number — RIO GRANDE ALCOHOLISM TREATMENT PROGRAM, INC.

Table of content: DR. CHRYSTAL FAYE ELLER MD (NPI 1487797114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558644161 NPI number — RIO GRANDE ALCOHOLISM TREATMENT PROGRAM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIO GRANDE ALCOHOLISM TREATMENT PROGRAM, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558644161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMBUDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87531-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-579-4253
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701-3832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-454-9611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MEDINA
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
505-579-4253

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  101YA0400X , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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