Healthcare Provider Details

I. General information

NPI: 1265665384
Provider Name (Legal Business Name): FULL LIFE OUTREACH MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 S BUCKNER BLVD
DALLAS TX
75227-4207
US

IV. Provider business mailing address

4545 S BUCKNER BLVD
DALLAS TX
75227-4207
US

V. Phone/Fax

Practice location:
  • Phone: 214-791-2863
  • Fax:
Mailing address:
  • Phone: 214-791-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number801062647
License Number StateTX

VIII. Authorized Official

Name: MR. REGINALD BENJAMIN
Title or Position: PRESIDENT
Credential:
Phone: 214-791-2863