Provider Demographics
NPI:1396282646
Name:PAIN REHABILITATION AND WELLNESS INSTITUTE LLC
Entity type:Organization
Organization Name:PAIN REHABILITATION AND WELLNESS INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KUCHAKULLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-732-9844
Mailing Address - Street 1:1623 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6528
Mailing Address - Country:US
Mailing Address - Phone:352-732-9844
Mailing Address - Fax:352-732-6787
Practice Address - Street 1:11740 SW 97TH TER
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-5273
Practice Address - Country:US
Practice Address - Phone:352-732-9844
Practice Address - Fax:352-854-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 208VP0000X
FLME78743207L00000X
FLME66726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty