Provider Demographics
NPI:1679905640
Name:LONE STAR CIRCLE OF CARE
Entity type:Organization
Organization Name:LONE STAR CIRCLE OF CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERIALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:5126-868-0207
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-626-0207
Mailing Address - Fax:
Practice Address - Street 1:902 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:TX
Practice Address - Zip Code:78621-2515
Practice Address - Country:US
Practice Address - Phone:512-626-0207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE STAR CIRCLE OF CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX513451041C0700X
TXP4217207Q00000X
TX816106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty