Healthcare Provider Details

I. General information

NPI: 1184024663
Provider Name (Legal Business Name): FIBROLIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 MAGNOLIA ST SUITE D
MADISON MS
39110-8903
US

IV. Provider business mailing address

742 MAGNOLIA ST SUITE D
MADISON MS
39110-8903
US

V. Phone/Fax

Practice location:
  • Phone: 601-856-9866
  • Fax: 601-856-9824
Mailing address:
  • Phone: 601-856-9866
  • Fax: 601-856-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21791
License Number StateMS

VIII. Authorized Official

Name: DR. PATRICK B WOOD
Title or Position: PRESIDENT AND CLINICIAN
Credential: M.D.
Phone: 601-856-9866