Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7716 LAKE JUNE ROAD
DALLAS TX
75217
US

IV. Provider business mailing address

7716 LAKE JUNE ROAD
DALLAS TX
75217
US

V. Phone/Fax

Practice location:
  • Phone: 214-398-8801
  • Fax:
Mailing address:
  • Phone: 214-398-8801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRUCE E. WARDLAY
Title or Position: OWNER
Credential: D.O.
Phone: 214-398-8801