Healthcare Provider Details

I. General information

NPI: 1073844049
Provider Name (Legal Business Name): SOUTHWEST CENTER FOR PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FIRST PLAZA CTR NW STE # 62
ALBUQUERQUE NM
87102-3355
US

IV. Provider business mailing address

PO BOX 984
BERNALILLO NM
87004-0984
US

V. Phone/Fax

Practice location:
  • Phone: 847-530-0236
  • Fax:
Mailing address:
  • Phone: 847-530-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number0016
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERT THOMAS SMITH
Title or Position: PRESIDENT
Credential: D.N.
Phone: 847-530-0236