Healthcare Provider Details

I. General information

NPI: 1689957060
Provider Name (Legal Business Name): NM PAIN CARE SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 PINEHURST RD SE SUITE 102
RIO RANCHO NM
87124-2219
US

IV. Provider business mailing address

914 PINEHURST RD SE SUITE 102
RIO RANCHO NM
87124-2219
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-9412
  • Fax: 505-896-9461
Mailing address:
  • Phone: 505-896-9412
  • Fax: 505-896-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROB MILLER
Title or Position: FRANCHISEE
Credential:
Phone: 505-896-9412