Healthcare Provider Details

I. General information

NPI: 1437390705
Provider Name (Legal Business Name): LONE STAR CIRCLE OF CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2423 WILLIAMS DR
GEORGETOWN TX
78628-3200
US

IV. Provider business mailing address

1500 WEST UNIVERSITY SUITE 103
GEORGETOWN TX
78628-7109
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-1124
  • Fax: 512-868-9894
Mailing address:
  • Phone: 512-868-1124
  • Fax: 512-868-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER C PERIALAS
Title or Position: CEO
Credential:
Phone: 512-868-1124