Basic Information
| Provider Information | |||||||||
| NPI: | 1669603361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONE STAR CIRCLE OF CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE AIRE MEDICAL CENTER | ||||||||
| 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: | 8778005722 | ||||||||
| FaxNumber: | 5128692940 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 WILLIAMS DR | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786283200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MUNDHENK | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5128681124 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONE STAR CIRCLE OF CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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) |
ID Information
| ID | Type | State | Issuer | Description | 2085110-01 | 05 | TX | MEDICAID |