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General NPI Number Information
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NPI Number | 1134685993
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Entity Type | Organization
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Legal Business Name | I360 LIFE DEVELOPMENT, LLC
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Dates
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Enumeration Date | 02/18/2019
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Last Update Date | 02/18/2019
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Provider Practice Location Address
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Address Line | 6600 LBJ FWY STE 240
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City | DALLAS
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State | TX
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Zip | 75240-6550
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Country | US
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Telephone | 214-533-5640
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Fax |
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Provider Business Mailing Address
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Address Line | 6600 LBJ FWY STE 240
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City | DALLAS
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State | TX
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Zip | 75240-6550
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Country | US
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Telephone | 214-533-5640
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Fax |
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. DESI JENSEN
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Credential |
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Telephone | 469-422-1262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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