Provider Demographics
NPI:1174540876
Name:LONE STAR WELLNESS
Entity type:Organization
Organization Name:LONE STAR WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-356-3813
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:QUINLAN
Mailing Address - State:TX
Mailing Address - Zip Code:75474
Mailing Address - Country:US
Mailing Address - Phone:903-356-3813
Mailing Address - Fax:903-356-3820
Practice Address - Street 1:525 HWY 34 SOUTH
Practice Address - Street 2:SUITE D
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474
Practice Address - Country:US
Practice Address - Phone:903-356-3813
Practice Address - Fax:903-356-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN
TX00W898Medicare PIN
TX=========OtherEIN