Provider Demographics
NPI: | 1437668951 |
---|---|
Name: | LONE STAR PROGRESSIVE MEDICINE OF BURLESON PA |
Entity Type: | Organization |
Organization Name: | LONE STAR PROGRESSIVE MEDICINE OF BURLESON PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/AUTHORIZED OFFICIAL |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | BRANDON |
Authorized Official - Last Name: | PETTKE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 817-297-7100 |
Mailing Address - Street 1: | 1320 NW JOHN JONES DR |
Mailing Address - Street 2: | |
Mailing Address - City: | BURLESON |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76028-8040 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 817-297-7100 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1320 NW JOHN JONES DR |
Practice Address - Street 2: | |
Practice Address - City: | BURLESON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76028-8040 |
Practice Address - Country: | US |
Practice Address - Phone: | 817-297-7100 |
Practice Address - Fax: | 817-297-7193 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-09-27 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty |