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NPI Code Detail

MEDICARE: LIVE WELL MD PA

MEDICARE: LIVE WELL MD PA
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
12086S0129XVascular Surgery PhysicianG1042TX

General Provider Information

NPI Number : 1265729453
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIVE WELL MD PA
Provider Business Mailing Address
First Line : 4808 S BUCKNER BLVD
Second Line :
City : DALLAS
State : TX
Zip : 75227-2348
Country : US
Telephone Number : 214-388-4808
Fax Number :
Provider Business Practice Location Address
First Line : 4808 S BUCKNER BLVD
Second Line :
City : DALLAS
State : TX
Zip : 75227-2348
Country : US
Telephone Number : 214-388-4808
Fax Number :
Authorized Official
Title or Position : OWNER
Name : HENRY T HORRILLENO
Credential : MD
Telephone Number : 214-388-4808
Provider Enumeration Date : 07/07/2011
Last Update Date : 07/07/2011

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