Healthcare Provider Details

I. General information

NPI: 1851411474
Provider Name (Legal Business Name): OKALOOSA PAIN CONSULTANTS P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5357
US

IV. Provider business mailing address

150 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5357
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-8004
  • Fax: 850-689-8086
Mailing address:
  • Phone: 850-689-8004
  • Fax: 850-689-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JANA KAY WOOD
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 850-689-8004