MEDICARE: ANDLYCO, 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1477935609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDLYCO, LLC

Provider Business Mailing Address
First Line	:	1803 CENTER ST
Second Line	:	SUITE A
City	:	DEER PARK
State	:	TX
Zip	:	77536-3598
Country	:	US
Telephone Number	:	281-476-4600
Fax Number	:	281-930-8856

Provider Business Practice Location Address
First Line	:	1002 ABC AVE
Second Line	:	SUITE 400
City	:	FREEPORT
State	:	TX
Zip	:	77541-3889
Country	:	US
Telephone Number	:	979-239-3000
Fax Number	:	979-239-3003

Authorized Official
Title or Position	:	CFO
Name	:	MRS. KARLA R MCCLELLAN
Credential	:	CPA
Telephone Number	:	281-476-4600

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	06/24/2015

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