Provider Demographics
NPI:1184861148
Name:OUTPATIENT PAIN & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:OUTPATIENT PAIN & WELLNESS CENTER, INC.
Other - Org Name:OUTPATIENT PAIN & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-874-6600
Mailing Address - Street 1:4602 N ARMENIA AVE
Mailing Address - Street 2:SUITE B5
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2626
Mailing Address - Country:US
Mailing Address - Phone:813-874-6600
Mailing Address - Fax:813-874-6601
Practice Address - Street 1:4602 N ARMENIA AVE
Practice Address - Street 2:SUITE B5
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2626
Practice Address - Country:US
Practice Address - Phone:813-874-6600
Practice Address - Fax:813-874-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7977111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL382225700Medicaid