Healthcare Provider Details

I. General information

NPI: 1831265776
Provider Name (Legal Business Name): ALABAMA PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WHITESPORT DRIVE SUITE A
HUNTSVILLE AL
35801
US

IV. Provider business mailing address

600 WHITESPORT DRIVE SUITE A
HUNTSVILLE AL
35801
US

V. Phone/Fax

Practice location:
  • Phone: 256-882-2003
  • Fax: 256-705-4630
Mailing address:
  • Phone: 256-882-2003
  • Fax: 256-705-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number895
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-075145
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number12320
License Number StateAL

VIII. Authorized Official

Name: DR. KENNETH DEAN WILLIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 256-882-2003