Provider Demographics
NPI:1467558759
Name:PRIME STAR HOME HEALTH OF CENTRAL TEXAS, INC.
Entity Type:Organization
Organization Name:PRIME STAR HOME HEALTH OF CENTRAL TEXAS, INC.
Other - Org Name:WIMBERLEY HEALTH SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, HCS-C
Authorized Official - Phone:318-259-1410
Mailing Address - Street 1:1527 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-259-1410
Mailing Address - Fax:318-532-6088
Practice Address - Street 1:5206 WIND RIVER RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4017
Practice Address - Country:US
Practice Address - Phone:512-847-7080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00603251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX006083OtherLICENSEDEPTOFAGING&DISABI
TX678174Medicare ID - Type UnspecifiedHOME HEALTH MEDICARE PROV