MEDICARE: LIFES SECOND CHANCE TREATMENT CENTER LAKISHA HENDERSON NELSON SOLE MBR

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	261QM2800X	Methadone Clinic	1000045	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1000045	OTHER	TX	PERMIT

General Provider Information

NPI Number	:	1821419201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFES SECOND CHANCE TREATMENT CENTER LAKISHA HENDERSON NELSON SOLE MBR

Provider Business Mailing Address
First Line	:	2615 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-3112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-3112
Country	:	US
Telephone Number	:	214-376-7388
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAKISHA HENDERSON
Credential	:
Telephone Number	:	469-360-6794

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	05/29/2020

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