Healthcare Provider Details

I. General information

NPI: 1154401669
Provider Name (Legal Business Name): FAYETTEVILLE LITHOTRIPTERS LIMITED PARTNERSHIP- LOUISIANA I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 STEAM WAY STE A102
ROUND ROCK TX
78665-2233
US

IV. Provider business mailing address

1990 STEAM WAY STE A102
ROUND ROCK TX
78665-2233
US

V. Phone/Fax

Practice location:
  • Phone: 877-465-4845
  • Fax: 512-872-5105
Mailing address:
  • Phone: 877-465-4845
  • Fax: 512-872-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LATANYA CASTILE
Title or Position: PAYER RELATIONS
Credential:
Phone: 847-544-5939