Basic Information
| Provider Information | |||||||||
| NPI: | 1770737454 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BASTROP LOST PINES CENTER FOR CANCER CARE LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BASTROP LOST PINES CENTER FOR CANCER CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842374 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752842374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125830205 | ||||||||
| FaxNumber: | 5125832001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3107 EAST HIGHWAY 71 | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786025156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123215700 | ||||||||
| FaxNumber: | 5123967640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2008 | ||||||||
| LastUpdateDate: | 10/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5123962500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | H3082 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.