Provider Demographics
NPI:1477213544
Name:AUSTIN REGIONAL CLINIC, PA
Entity Type:Organization
Organization Name:AUSTIN REGIONAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGHESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-419-0707
Mailing Address - Street 1:6210 E US HWY 290
Mailing Address - Street 2:SUITE 240 - CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1098
Mailing Address - Country:US
Mailing Address - Phone:512-338-3802
Mailing Address - Fax:512-406-6212
Practice Address - Street 1:12779 WEST SH 29
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642
Practice Address - Country:US
Practice Address - Phone:512-778-7003
Practice Address - Fax:512-406-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1333940-07Medicaid