MEDICARE: FULL LIFE OUTREACH MEDICAL CENTER LLC

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	1041C0700X	Clinical Social Worker	801062647	TX

General Provider Information

NPI Number	:	1265665384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL LIFE OUTREACH MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	4545 S BUCKNER BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-4207
Country	:	US
Telephone Number	:	214-791-2863
Fax Number	:

Provider Business Practice Location Address
First Line	:	4545 S BUCKNER BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-4207
Country	:	US
Telephone Number	:	214-791-2863
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. REGINALD BENJAMIN
Credential	:
Telephone Number	:	214-791-2863

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	12/15/2025

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