Healthcare Provider Details

I. General information

NPI: 1104471085
Provider Name (Legal Business Name): KELLEN J PINO MS, LAT, ATC, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 LOMAS BLVD NE
ALBUQUERQUE NM
87112-5804
US

IV. Provider business mailing address

4500 SHADOW AVE NW
ALBUQUERQUE NM
87114-5063
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-2200
  • Fax:
Mailing address:
  • Phone: 505-681-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number424
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: