Healthcare Provider Details

I. General information

NPI: 1649600255
Provider Name (Legal Business Name): LONE STAR CIRCLE OF CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5339 N IH 35 SUITE 100
AUSTIN TX
78723-2428
US

IV. Provider business mailing address

205 E UNIVERSITY AVE SUITE 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 Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER PERIALAS JR.
Title or Position: CEO
Credential:
Phone: 877-800-5722