Healthcare Provider Details

I. General information

NPI: 1396282646
Provider Name (Legal Business Name): PAIN REHABILITATION AND WELLNESS INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 SW 97TH TER
OCALA FL
34481-5273
US

IV. Provider business mailing address

1623 SW 1ST AVE
OCALA FL
34471-6528
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-9844
  • Fax: 352-854-9966
Mailing address:
  • Phone: 352-732-9844
  • Fax: 352-732-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME78743
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME66726
License Number StateFL

VIII. Authorized Official

Name: MR. KUCHAKULLA N REDDY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 352-732-9844