MEDICARE: 1ST LIFE PLANNING RESIDENTIAL, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1316380223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1ST LIFE PLANNING RESIDENTIAL, LLC

Provider Business Mailing Address
First Line	:	3939 BELT LINE RD
Second Line	:	SUITE 310
City	:	ADDISON
State	:	TX
Zip	:	75001-4323
Country	:	US
Telephone Number	:	972-964-3444
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 BELT LINE RD
Second Line	:	SUITE 310
City	:	ADDISON
State	:	TX
Zip	:	75001-4323
Country	:	US
Telephone Number	:	972-964-3444
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ERIC BRANDENBURG
Credential	:
Telephone Number	:	214-618-1722

Provider Enumeration Date	:	04/10/2013
Last Update Date	:	04/10/2013

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