Provider Demographics
NPI:1154845840
Name:HEALTHY LIVING FAMILY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:HEALTHY LIVING FAMILY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WYCONDAROGA
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-402-0174
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:MS
Mailing Address - Zip Code:38746-0357
Mailing Address - Country:US
Mailing Address - Phone:662-987-5023
Mailing Address - Fax:662-987-5025
Practice Address - Street 1:820 ASHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:GUNNISION
Practice Address - State:MS
Practice Address - Zip Code:38746
Practice Address - Country:US
Practice Address - Phone:662-987-5023
Practice Address - Fax:662-987-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
MS890243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04784050Medicaid