# INTERVENTIONAL AND FUNCTIONAL PAIN CENTER

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164907804
- **Authorized official:** JUAN CARLOS MIRT (OFFICE MANAGER)
- **Authorized official phone:** (401) 648-6100

## Contact information

- **Practice address:** 1150 RESERVOIR AVE STE 200, CRANSTON, RI 02920-6043
- **Practice address phone:** (401) 648-6100
- **Mailing address:** 1150 RESERVOIR AVE STE 200, CRANSTON, RI 02920-6043
- **Mailing address phone:** (401) 648-6100

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |
| 261QP2000X | Physical Therapy Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 09/28/2018
- **Last updated:** 01/22/2025