Provider Demographics
NPI:1497876288
Name:KINGSLEY MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:KINGSLEY MEDICAL CLINIC, P.A.
Other - Org Name:RIDGEWOOD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WARDLAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-271-5544
Mailing Address - Street 1:219 W KINGSLEY RD
Mailing Address - Street 2:SUIT 336
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-3448
Mailing Address - Country:US
Mailing Address - Phone:972-271-5544
Mailing Address - Fax:
Practice Address - Street 1:219 W KINGSLEY RD
Practice Address - Street 2:SUIT 336
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-3448
Practice Address - Country:US
Practice Address - Phone:972-271-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00973VMedicare ID - Type Unspecified