Healthcare Provider Details

I. General information

NPI: 1982201190
Provider Name (Legal Business Name): ORTHOLONESTAR, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 S DONNYBROOK AVE
TYLER TX
75701-4216
US

IV. Provider business mailing address

3414 GOLDEN RD
TYLER TX
75701-8336
US

V. Phone/Fax

Practice location:
  • Phone: 903-939-7500
  • Fax: 903-939-7728
Mailing address:
  • Phone: 903-939-7500
  • Fax: 903-939-7728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER KINMAN
Title or Position: CEO
Credential:
Phone: 512-439-1000