Basic Information
| Provider Information | |||||||||
| NPI: | 1396282646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN REHABILITATION AND WELLNESS INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1623 SW 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344716528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527329844 | ||||||||
| FaxNumber: | 3527326787 | ||||||||
| Practice Location | |||||||||
| Address1: | 11740 SW 97TH TER | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344815273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527329844 | ||||||||
| FaxNumber: | 3528549966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | REDDY | ||||||||
| AuthorizedOfficialFirstName: | KUCHAKULLA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3527329844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207L00000X | ME78743 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207R00000X | ME66726 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.