Provider Demographics
NPI:1104471085
Name:PINO, KELLEN J (MS, LAT, ATC, CES)
Entity type:Individual
Prefix:MR
First Name:KELLEN
Middle Name:J
Last Name:PINO
Suffix:
Gender:M
Credentials:MS, LAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SHADOW AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5063
Mailing Address - Country:US
Mailing Address - Phone:505-681-0748
Mailing Address - Fax:
Practice Address - Street 1:12200 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5804
Practice Address - Country:US
Practice Address - Phone:505-559-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4242083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine