MEDICARE: LAKE JUNE MEDICAL CENTER, P.A.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1598886822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE JUNE MEDICAL CENTER, P.A.

Provider Business Mailing Address
First Line	:	7716 LAKE JUNE ROAD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217
Country	:	US
Telephone Number	:	214-398-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	7716 LAKE JUNE ROAD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217
Country	:	US
Telephone Number	:	214-398-8801
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRUCE E. WARDLAY
Credential	:	D.O.
Telephone Number	:	214-398-8801

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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