Provider Demographics
NPI:1396930152
Name:CARLSBAD SPINE PAIN SPORTS MEDICINE PC
Entity type:Organization
Organization Name:CARLSBAD SPINE PAIN SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-628-1548
Mailing Address - Street 1:2319 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3515
Mailing Address - Country:US
Mailing Address - Phone:575-628-1548
Mailing Address - Fax:505-628-1552
Practice Address - Street 1:2319 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3515
Practice Address - Country:US
Practice Address - Phone:505-628-1548
Practice Address - Fax:505-628-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000325208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9615Medicaid
G12632Medicare UPIN
NMB9615Medicaid