1972866200 NPI number — LONE STAR CIRCLE OF CARE

Table of content: (NPI 1972866200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972866200 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:
Provider Other Organization Name Type Code:
6
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:
1972866200
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:
512-686-0207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 SCENIC DR
Provider Second Line Business Practice Location Address:
SUITE 3326
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78626-7724
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:
512-869-1788
Provider Enumeration Date:
06/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CALVIN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
DAVID
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: 3082265-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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