Healthcare Provider Details

I. General information

NPI: 1932964715
Provider Name (Legal Business Name): SANDIA PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 CANDELARIA RD NE STE E
ALBUQUERQUE NM
87112-1034
US

IV. Provider business mailing address

8501 CANDELARIA RD NE STE H
ALBUQUERQUE NM
87112-1034
US

V. Phone/Fax

Practice location:
  • Phone: 505-420-4971
  • Fax: 505-384-6594
Mailing address:
  • Phone: 505-420-4971
  • Fax: 505-384-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL KNIGHT
Title or Position: CONSULTANT
Credential: PRACTICE CONSULTANT
Phone: 915-328-4793