=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588997712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPAN RESOURCES OF TEXAS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2009
-----------------------------------------------------
Last Update Date | 09/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3918 S DENLEY DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75216-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-433-9750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3918 S DENLEY DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75216-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-433-9750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. TIEZO DEVOTNAE ADKISON
-----------------------------------------------------
Credential | LVN, RAC-CT, CNAC
-----------------------------------------------------
Telephone | 682-433-9750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------