Provider Demographics
NPI:1629013230
Name:MNM LONESTAR REHABILITATION, INC.
Entity Type:Organization
Organization Name:MNM LONESTAR REHABILITATION, INC.
Other - Org Name:LONESTAR REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMIERA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CERT MDT
Authorized Official - Phone:940-595-0566
Mailing Address - Street 1:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-0634
Mailing Address - Country:US
Mailing Address - Phone:940-595-0566
Mailing Address - Fax:
Practice Address - Street 1:915 AVENUE C
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-6545
Practice Address - Country:US
Practice Address - Phone:940-595-0566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0001NFOtherBCBS
TX179288901Medicaid
TX00W053Medicare PIN