Basic Information
| Provider Information | |||||||||
| NPI: | 1336459353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONE STAR ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 BEAR CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762482500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173373671 | ||||||||
| FaxNumber: | 8173373620 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 BEAR CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762482500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173373671 | ||||||||
| FaxNumber: | 8173373620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLACH | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7133430832 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 130072 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00973173 | 01 | TX | RAILROAD MEDICARE | OTHER |