Healthcare Provider Details

I. General information

NPI: 1164907804
Provider Name (Legal Business Name): INTERVENTIONAL AND FUNCTIONAL PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 RESERVOIR AVE STE 200
CRANSTON RI
02920-6043
US

IV. Provider business mailing address

1150 RESERVOIR AVE STE 200
CRANSTON RI
02920-6043
US

V. Phone/Fax

Practice location:
  • Phone: 401-648-6100
  • Fax:
Mailing address:
  • Phone: 401-648-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUAN CARLOS MIRT
Title or Position: OFFICE MANAGER
Credential:
Phone: 401-648-6100