MEDICARE: LIFE'S GOOD CLINIC LLC

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	174400000X	Specialist	M4838	TX
2	363LP2300X	Primary Care Nurse Practitioner	708487	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	237238	OTHER	NY	PROVIDER LISCENSE NUMBER

General Provider Information

NPI Number	:	1073869939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE'S GOOD CLINIC LLC

Provider Business Mailing Address
First Line	:	6060 BELLAIRE BLVD STE A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-5425
Country	:	US
Telephone Number	:	713-660-8045
Fax Number	:	713-660-8950

Provider Business Practice Location Address
First Line	:	6060 BELLAIRE BLVD STE A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-5425
Country	:	US
Telephone Number	:	713-660-8045
Fax Number	:	713-660-8950

Authorized Official
Title or Position	:	OWNER
Name	:	MS. LINDA LANDRY
Credential	:
Telephone Number	:	713-660-8045

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	09/26/2012

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Directions to “LIFE'S GOOD CLINIC LLC ” Practice Location

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