Basic Information
| Provider Information | |||||||||
| NPI: | 1578515987 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONE STAR CIRCLE OF CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRANGER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786287108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128681124 | ||||||||
| FaxNumber: | 5128689894 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WEST DAVILLA | ||||||||
| Address2: | |||||||||
| City: | GRANGER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128592251 | ||||||||
| FaxNumber: | 5128592575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | PERIALAS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5128681124 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.