Provider Demographics
NPI:1710284542
Name:LONE STAR CIRCLE OF CARE
Entity Type:Organization
Organization Name:LONE STAR CIRCLE OF CARE
Other - Org Name:LONE STAR CIRCLE OF CARE PEDIATRICS AT HARKER HEIGHTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CALVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-994-1933
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-868-1124
Mailing Address - Fax:
Practice Address - Street 1:200 NOLA RUTH BLVD
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-6074
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:254-698-1673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE STAR CIRCLE OF CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2808107-01Medicaid
67-1966Medicare PIN