Provider Demographics
NPI:1093147951
Name:COOSA PAIN AND WELLNESS
Entity Type:Organization
Organization Name:COOSA PAIN AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-442-6181
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902-0266
Mailing Address - Country:US
Mailing Address - Phone:256-442-6181
Mailing Address - Fax:
Practice Address - Street 1:3804 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-3051
Practice Address - Country:US
Practice Address - Phone:256-952-2200
Practice Address - Fax:256-952-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty