Healthcare Provider Details

I. General information

NPI: 1053945147
Provider Name (Legal Business Name): INTERVENTIONAL PAIN ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 MCMAHON BLVD NW STE 109
ALBUQUERQUE NM
87114-5412
US

IV. Provider business mailing address

4824 MCMAHON BLVD NW STE 109
ALBUQUERQUE NM
87114-5412
US

V. Phone/Fax

Practice location:
  • Phone: 210-464-4234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHU RAITEN
Title or Position: OWNER
Credential: MD
Phone: 210-464-4234