=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164354361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 360 MEDICAL GROUP TEXAS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2026
-----------------------------------------------------
Last Update Date | 06/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5900 BALCONES DR STE 100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-4298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-645-1192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 BALCONES DR STE 100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-4298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JAMES VILLAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-645-1192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------