Provider Demographics
NPI:1336878909
Name:PAIN AND WELLNESS INSTITUTE OF KENTUCKY LLC
Entity Type:Organization
Organization Name:PAIN AND WELLNESS INSTITUTE OF KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-876-6474
Mailing Address - Street 1:10302 BROOKRIDGE VILLAGE BLVD STE 103-104
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4475
Mailing Address - Country:US
Mailing Address - Phone:502-576-5300
Mailing Address - Fax:502-576-5376
Practice Address - Street 1:10302 BROOKRIDGE VILLAGE BLVD STE 103-104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4475
Practice Address - Country:US
Practice Address - Phone:502-576-5300
Practice Address - Fax:502-576-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty