Healthcare Provider Details

I. General information

NPI: 1174759385
Provider Name (Legal Business Name): LONE STAR EXPEDITIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 FOREST ROAD 5101
GROVETON TX
75845
US

IV. Provider business mailing address

1728 FOREST ROAD 5101
GROVETON TX
75845
US

V. Phone/Fax

Practice location:
  • Phone: 936-831-3133
  • Fax:
Mailing address:
  • Phone: 936-831-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number822139
License Number StateTX

VIII. Authorized Official

Name: MS. MARY C, COVINGTON
Title or Position: INSURANCE BILLER
Credential:
Phone: 801-466-3838