Provider Demographics
NPI:1629392063
Name:LAKE COUNTRY FAMILY MEDICINE, P.A.
Entity Type:Organization
Organization Name:LAKE COUNTRY FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YUNG
Authorized Official - Middle Name:SIEU
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-260-0535
Mailing Address - Street 1:8465 BOAT CLUB RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3607
Mailing Address - Country:US
Mailing Address - Phone:817-260-0535
Mailing Address - Fax:
Practice Address - Street 1:8465 BOAT CLUB RD
Practice Address - Street 2:SUITE 115
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3607
Practice Address - Country:US
Practice Address - Phone:817-260-0535
Practice Address - Fax:817-984-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TXK7694261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2144495Medicaid
TX2144495Medicaid