Healthcare Provider Details

I. General information

NPI: 1477860435
Provider Name (Legal Business Name): PROGRESSIVE LIFE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17016 COPPERHEAD DR
ROUND ROCK TX
78664-8616
US

IV. Provider business mailing address

2579 WESTERN TRAILS BLVD
AUSTIN TX
78745-1578
US

V. Phone/Fax

Practice location:
  • Phone: 512-892-2191
  • Fax:
Mailing address:
  • Phone: 512-892-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY BOWERS
Title or Position: PRESIDENT
Credential:
Phone: 210-340-7155