Healthcare Provider Details

I. General information

NPI: 1851856454
Provider Name (Legal Business Name): MEDCARE FAMILY AND SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15110 DALLAS PKWY STE 102
DALLAS TX
75248-4601
US

IV. Provider business mailing address

PO BOX 1142
ADDISON TX
75001-1142
US

V. Phone/Fax

Practice location:
  • Phone: 972-792-0204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAWNA BOUDREAUX
Title or Position: OPERATIONS
Credential:
Phone: 972-792-0204