MEDICARE: PAIN MANAGEMENT CLINICS OF NEW MEXICO, INC.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	I-1464	NM
2	225700000X	Massage Therapist	4735	NM
3	225700000X	Massage Therapist	3659	NM
4	208VP0000X	Pain Medicine Physician	94-300	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	201013423	OTHER	NM	PRESBYTERIAN HEALTH ID
3	00NM003410	OTHER	NM	BLUE SHIELD ID NUMBER

General Provider Information

NPI Number	:	1144364472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT CLINICS OF NEW MEXICO, INC.

Provider Business Mailing Address
First Line	:	8005 PENNSYLVANIA CIR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-7810
Country	:	US
Telephone Number	:	505-248-0698
Fax Number	:	505-248-0798

Provider Business Practice Location Address
First Line	:	8005 PENNSYLVANIA CIR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-7810
Country	:	US
Telephone Number	:	505-248-0698
Fax Number	:	505-248-0798

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOAN P LEWIS
Credential	:	M.D.
Telephone Number	:	505-248-0698

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	06/21/2018

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