1629392063 NPI number — LAKE COUNTRY FAMILY MEDICINE, P.A.

Table of content: MS. KATHERINE DIGNAN MS, RD, LD, CDCES (NPI 1417285990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629392063 NPI number — LAKE COUNTRY FAMILY MEDICINE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE COUNTRY FAMILY MEDICINE, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629392063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8465 BOAT CLUB RD
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76179-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-260-0535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8465 BOAT CLUB RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76179-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-260-0535
Provider Business Practice Location Address Fax Number:
817-984-1448
Provider Enumeration Date:
03/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CHEN
Authorized Official First Name:
YUNG
Authorized Official Middle Name:
SIEU
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-260-0535

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  K7694 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2144495 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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