1376840140 NPI number — LONE STAR CIRCLE OF CARE

Table of content: (NPI 1376840140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376840140 NPI number — LONE STAR CIRCLE OF CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONE STAR CIRCLE OF CARE
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:
LONE STAR CIRCLE OF CARE AT KILLEEN
Provider Other Organization Name Type Code:
3
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:
1376840140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 E UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78626-6814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-868-1124
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 S CLEAR CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76549-4985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-800-5722
Provider Business Practice Location Address Fax Number:
254-554-3741
Provider Enumeration Date:
02/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CALVIN
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
512-994-1933

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2186900-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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