MEDICARE: BERGEN LEMACK

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1952293961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERGEN LEMACK

Provider Business Mailing Address
First Line	:	3001 CROCKETT ST APT 1467
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3278
Country	:	US
Telephone Number	:	972-757-6983
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 CROCKETT ST APT 1467
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3278
Country	:	US
Telephone Number	:	972-757-6983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2025
Last Update Date	:	07/16/2025

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Directions to “ BERGEN LEMACK ” Practice Location

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