MEDICARE: ADVANCED LIFE WELLNESS INSTITUTE, INC.

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1538586383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED LIFE WELLNESS INSTITUTE, INC.

Provider Business Mailing Address
First Line	:	1917 ASHLAND ST # 2888
Second Line	:	IN SELECT SPECIALTY HOSPITAL
City	:	HOUSTON
State	:	TX
Zip	:	77008-3907
Country	:	US
Telephone Number	:	713-802-2883
Fax Number	:	713-802-2884

Provider Business Practice Location Address
First Line	:	1917 ASHLAND ST # 2888
Second Line	:	IN SELECT SPECIALTY HOSPITAL
City	:	HOUSTON
State	:	TX
Zip	:	77008-3907
Country	:	US
Telephone Number	:	713-802-2883
Fax Number	:	713-802-2884

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	CONNIE LI
Credential	:
Telephone Number	:	713-802-2883

Provider Enumeration Date	:	03/18/2014
Last Update Date	:	03/18/2014

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