Organization
LIVEWELL PASSPORT OF VA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEREMIAH D FABRY DC FNP (MANAGER)
(804) 229-1554
Entity
Organization
Contact information
Practice address
13553 MIDLOTHIAN TPKE, MIDLOTHIAN, VA 23113-4261
(804) 229-1554
(844) 777-1754
Mailing address
15801 SWINDON WAY, MIDLOTHIAN, VA 23112-5531
(804) 229-1554
(844) 777-1754
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
06/02/2023
Last updated
06/02/2023
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