MEDICARE: ADVANCED LIFE WELLNESS INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	F9771	TX
2	302R00000X	Health Maintenance Organization	G7070	TX

General Provider Information

NPI Number	:	1215273255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED LIFE WELLNESS INSTITUTE

Provider Business Mailing Address
First Line	:	1917 ASHLAND ST STE 2888
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-3907
Country	:	US
Telephone Number	:	713-802-2883
Fax Number	:	186-676-0055

Provider Business Practice Location Address
First Line	:	1917 ASHLAND ST STE 2888
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-3907
Country	:	US
Telephone Number	:	713-802-2883
Fax Number	:	186-676-0055

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MICHELLE LUONG
Credential	:
Telephone Number	:	713-802-2883

Provider Enumeration Date	:	12/19/2012
Last Update Date	:	12/19/2012

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Directions to “ADVANCED LIFE WELLNESS INSTITUTE ” Practice Location

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