Healthcare Provider Details

I. General information

NPI: 1093188096
Provider Name (Legal Business Name): WILLOW PAIN AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 JEFFERSON DAVIS DR
OXFORD MS
38655-5221
US

IV. Provider business mailing address

PO BOX 2730
OXFORD MS
38655-4200
US

V. Phone/Fax

Practice location:
  • Phone: 662-638-0462
  • Fax: 866-658-0083
Mailing address:
  • Phone: 662-638-0462
  • Fax: 866-658-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KIRK L. KINARD
Title or Position: OWNER
Credential: MD
Phone: 662-638-0462