Healthcare Provider Details

I. General information

NPI: 1881602167
Provider Name (Legal Business Name): RICHEY E. WOODS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1397 LITTON RD
SHAW MS
38773-9560
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax:
Mailing address:
  • Phone: 662-721-3349
  • Fax: 662-754-2233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0011
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: