# LIFE SPAN MEDICINE PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679514632
- **Authorized official:** GINA RENNA (CEO)
- **Authorized official phone:** (214) 303-1888

## Contact information

- **Practice address:** 2706 FAIRMONT STREET, DALLAS, TX 75201
- **Practice address phone:** (214) 303-1888
- **Practice address fax:** (214) 303-1550
- **Mailing address:** 2706 FAIRMONT STREET, DALLAS, TX 75201

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 06/09/2006
- **Last updated:** 04/07/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0036HZ | BLUE CROSS | — |