Healthcare Provider Details

I. General information

NPI: 1770954281
Provider Name (Legal Business Name): SPORTS AND PAIN INTERVENTIONS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C55 CALLE 4 URB. MONTE BELLO
HORMIGUEROS PR
00660
US

IV. Provider business mailing address

PO BOX 6216
MAYAGUEZ PR
00681-6216
US

V. Phone/Fax

Practice location:
  • Phone: 787-673-3299
  • Fax:
Mailing address:
  • Phone: 787-673-3299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number18031
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number18031
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number18031
License Number StatePR

VIII. Authorized Official

Name: DR. RAFAEL J ACEVEDO
Title or Position: PRESIDENT
Credential:
Phone: 787-673-3299