Provider Demographics
NPI:1689473068
Name:LIFEGENIX MED PLLC
Entity type:Organization
Organization Name:LIFEGENIX MED PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-236-3333
Mailing Address - Street 1:17230 DALLAS PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1136
Mailing Address - Country:US
Mailing Address - Phone:972-236-3333
Mailing Address - Fax:972-920-3754
Practice Address - Street 1:17230 DALLAS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1136
Practice Address - Country:US
Practice Address - Phone:972-236-3333
Practice Address - Fax:972-920-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty