=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104785591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUX FUSION WELLNESS & MEDSPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2026
-----------------------------------------------------
Last Update Date | 08/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7617 LAKEVIEW PKWY
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-278-0657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8501 HUNTINGTON DR
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75089-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-278-0657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JEFFREY S WALLACE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 469-278-0657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------