Basic Information
Provider Information | |||||||||
NPI: | 1447586961 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONE STAR CIRCLE OF CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TEXAS A & M HEALTH SCIENCE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 E UNIVERSITY AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786266814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128681124 | ||||||||
FaxNumber: | 5128689894 | ||||||||
Practice Location | |||||||||
Address1: | 3950 N A W GRIMES BLVD | ||||||||
Address2: |   | ||||||||
City: | ROUND ROCK | ||||||||
State: | TX | ||||||||
PostalCode: | 786653540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778005722 | ||||||||
FaxNumber: | 5128689894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2009 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUNDHENK | ||||||||
AuthorizedOfficialFirstName: | RHONDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5128681124 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LONE STAR CIRCLE OF CARE | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 2104234-01 | 05 | TX |   | MEDICAID |