Provider Demographics
NPI:1720317365
Name:FOUR CORNERS PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:FOUR CORNERS PAIN MANAGEMENT LLC
Other - Org Name:FOUR CORNERS SPINE AND PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:OROZCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-326-7246
Mailing Address - Street 1:2500 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-326-7246
Mailing Address - Fax:505-592-0063
Practice Address - Street 1:2500 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-326-7246
Practice Address - Fax:505-592-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDR0371OtherR R MEDICARE
AZ484941Medicaid
NM88586251Medicaid
CO61029262Medicaid
UT1720317365Medicaid
NMNMA100144Medicare PIN