Provider Demographics
NPI:1316163587
Name:LIFEGUARD FAMILY HEALTH L.L.C.
Entity type:Organization
Organization Name:LIFEGUARD FAMILY HEALTH L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-566-7725
Mailing Address - Street 1:13706 COUNTY ROAD 291
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-4844
Mailing Address - Country:US
Mailing Address - Phone:903-566-7725
Mailing Address - Fax:
Practice Address - Street 1:1121 E SOUTHEAST LOOP 323 STE 102
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9660
Practice Address - Country:US
Practice Address - Phone:903-561-1071
Practice Address - Fax:903-561-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146782101Medicaid
TX8D2794Medicare ID - Type Unspecified
TX146782101Medicaid