Provider Demographics
NPI:1528015476
Name:SPINE & PAIN INSTITUTE OF SANTA FE, LLC
Entity Type:Organization
Organization Name:SPINE & PAIN INSTITUTE OF SANTA FE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GENOVESE ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-983-5200
Mailing Address - Street 1:P O BOX 6140
Mailing Address - Street 2:
Mailing Address - City:SANTE FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6140
Mailing Address - Country:US
Mailing Address - Phone:505-983-5200
Mailing Address - Fax:505-983-5202
Practice Address - Street 1:435 ST. MICHAEL'S DRIVE
Practice Address - Street 2:SUITE A-202
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7672
Practice Address - Country:US
Practice Address - Phone:505-983-5200
Practice Address - Fax:505-983-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty