Healthcare Provider Details

I. General information

NPI: 1154845840
Provider Name (Legal Business Name): HEALTHY LIVING FAMILY MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ASHLAND AVENUE
GUNNISION MS
38746
US

IV. Provider business mailing address

PO BOX 357
GUNNISON MS
38746-0357
US

V. Phone/Fax

Practice location:
  • Phone: 662-987-5023
  • Fax: 662-987-5025
Mailing address:
  • Phone: 662-987-5023
  • Fax: 662-987-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number890243
License Number StateMS

VIII. Authorized Official

Name: WYCONDAROGA E THOMAS
Title or Position: NURSE PRACTITIONER/OWNER
Credential: FNP-C
Phone: 662-402-0174