MEDICARE: WELLLIFE LABS 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1316390768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLLIFE LABS LLC

Provider Business Mailing Address
First Line	:	9777 W GULF BANK RD
Second Line	:	STE 5
City	:	HOUSTON
State	:	TX
Zip	:	77040-3132
Country	:	US
Telephone Number	:	281-970-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	19073 I 45 S STE 145
Second Line	:
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8744
Country	:	US
Telephone Number	:	281-970-5900
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	WAYNE WILSON
Credential	:
Telephone Number	:	281-970-5900

Provider Enumeration Date	:	07/21/2016
Last Update Date	:	07/21/2016

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