1184024663 NPI number — FIBROLIVING LLC

Table of content: (NPI 1184024663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184024663 NPI number — FIBROLIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIBROLIVING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184024663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
742 MAGNOLIA ST
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-8903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-856-9866
Provider Business Mailing Address Fax Number:
601-856-9824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
742 MAGNOLIA ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39110-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-856-9866
Provider Business Practice Location Address Fax Number:
601-856-9824
Provider Enumeration Date:
09/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT AND CLINICIAN
Authorized Official Telephone Number:
601-856-9866

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  21791 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1528086915 . This is a "PROVIDER PERSONAL NPI" identifier . This identifiers is of the category "OTHER".




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