MEDICARE: LIFEVANTAGE HOUSE CALLS PLLC

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	:	1679963771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEVANTAGE HOUSE CALLS PLLC

Provider Business Mailing Address
First Line	:	9101 NIGHTINGALE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2713
Country	:	US
Telephone Number	:	817-739-4007
Fax Number	:

Provider Business Practice Location Address
First Line	:	9101 NIGHTINGALE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2713
Country	:	US
Telephone Number	:	817-739-4007
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAYMOND ANDRADA
Credential	:
Telephone Number	:	817-739-4007

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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