Provider Demographics
NPI:1033245923
Name:MCKENNA MEDICAL GROUP
Entity Type:Organization
Organization Name:MCKENNA MEDICAL GROUP
Other - Org Name:LAKEVIEW CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:V.P. PHYSICIAN SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-606-9111
Mailing Address - Street 1:921 LAKEVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-4135
Mailing Address - Country:US
Mailing Address - Phone:210-620-7744
Mailing Address - Fax:
Practice Address - Street 1:921 LAKEVIEW BLVD
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4135
Practice Address - Country:US
Practice Address - Phone:210-620-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOOY940OtherPTAN
TX524221OtherNON-PROFIT HEALTH ORGANIZ