Provider Demographics
NPI:1033223706
Name:BLUEBONNET FAMILY CARE
Entity Type:Organization
Organization Name:BLUEBONNET FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-655-7969
Mailing Address - Street 1:223 S ABE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6305
Mailing Address - Country:US
Mailing Address - Phone:325-655-7969
Mailing Address - Fax:325-655-7976
Practice Address - Street 1:2030 PULLIAM ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76905-5175
Practice Address - Country:US
Practice Address - Phone:325-653-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0045MAOtherBCBS OF TX
TXA67492Medicare UPIN
TX00807XMedicare ID - Type UnspecifiedGROUP NUMBER