Healthcare Provider Details

I. General information

NPI: 1821695081
Provider Name (Legal Business Name): MODERN PAIN & SPINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 JUAN TABO BLVD NE STE A
ALBUQUERQUE NM
87112-4460
US

IV. Provider business mailing address

1540 JUAN TABO BLVD NE STE A
ALBUQUERQUE NM
87112-4460
US

V. Phone/Fax

Practice location:
  • Phone: 505-319-0231
  • Fax:
Mailing address:
  • Phone: 505-800-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ATHANASIOS KOSTANDINOS MANOLE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 505-800-7246