Healthcare Provider Details

I. General information

NPI: 1356766166
Provider Name (Legal Business Name): LONE STAR CIRCLE OF CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 38TH ST STE. 212
AUSTIN TX
78731-6400
US

IV. Provider business mailing address

205 E UNIVERSITY AVE STE. 200
GEORGETOWN TX
78626-6814
US

V. Phone/Fax

Practice location:
  • Phone: 877-800-5722
  • Fax:
Mailing address:
  • Phone: 877-800-5722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberP6469
License Number StateTX

VIII. Authorized Official

Name: MR. PETER C. PERIALES
Title or Position: CEO
Credential:
Phone: 512-686-0207