Provider Demographics
NPI:1770817322
Name:LAKE FOREST FAMILY HEALTH, PLLC
Entity Type:Organization
Organization Name:LAKE FOREST FAMILY HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WASHINGTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5170
Mailing Address - Street 1:4987 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-5072
Mailing Address - Country:US
Mailing Address - Phone:972-542-8464
Mailing Address - Fax:972-542-8468
Practice Address - Street 1:4987 W UNIVERSITY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-5072
Practice Address - Country:US
Practice Address - Phone:972-542-8464
Practice Address - Fax:972-542-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6565207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00942831OtherRAILROAD MEDICARE
TX284230401Medicaid
TX284230401Medicaid
TXP00942831OtherRAILROAD MEDICARE