Basic Information
| Provider Information | |||||||||
| NPI: | 1588096473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONE STAR CIRCLE OF CARE | ||||||||
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| OtherOrganizationName: | LONE STAR CIRCLE OF CARE @ HUTTO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E UNIVERSITY AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786266814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126860207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 FM 685 | ||||||||
| Address2: | |||||||||
| City: | HUTTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786345540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126860207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | PERIALAS | ||||||||
| AuthorizedOfficialFirstName: | PETE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5126860207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONE STAR CIRCLE OF CARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 53594 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LF0000X | 660624 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | P4217 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.