Provider Demographics
NPI:1851797427
Name:LIFEVANTAGE HOME HEALTH, LLC
Entity Type:Organization
Organization Name:LIFEVANTAGE HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERSON
Authorized Official - Middle Name:PINOTE
Authorized Official - Last Name:CONSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-541-4153
Mailing Address - Street 1:110 SW THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-3818
Mailing Address - Country:US
Mailing Address - Phone:817-541-4153
Mailing Address - Fax:
Practice Address - Street 1:110 SW THOMAS ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3818
Practice Address - Country:US
Practice Address - Phone:817-541-4153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health