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General NPI Number Information
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NPI Number | 1629392063
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Entity Type | Organization
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Legal Business Name | LAKE COUNTRY FAMILY MEDICINE, P.A.
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Dates
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Enumeration Date | 03/14/2010
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Last Update Date | 10/03/2023
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Provider Practice Location Address
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Address Line | 8465 BOAT CLUB RD SUITE 115
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City | FORT WORTH
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State | TX
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Zip | 76179-3607
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Country | US
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Telephone | 817-260-0535
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Fax | 817-984-1448
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Provider Business Mailing Address
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Address Line | 8465 BOAT CLUB RD SUITE 115
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City | FORT WORTH
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State | TX
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Zip | 76179-3607
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Country | US
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Telephone | 817-260-0535
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. YUNG SIEU CHEN
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Credential | D.O.
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Telephone | 817-260-0535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | K7694
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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