MEDICARE: LIFESPAN RESOURCES OF TEXAS, INC.

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1588997712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN RESOURCES OF TEXAS, INC.

Provider Business Mailing Address
First Line	:	3918 S DENLEY DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-5617
Country	:	US
Telephone Number	:	682-433-9750
Fax Number	:

Provider Business Practice Location Address
First Line	:	3918 S DENLEY DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-5617
Country	:	US
Telephone Number	:	682-433-9750
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. TIEZO DEVOTNAE ADKISON
Credential	:	LVN, RAC-CT, CNAC
Telephone Number	:	682-433-9750

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	09/04/2009

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