Provider Demographics
NPI:1790937738
Name:LONE STAR CIRCLE OF CARE
Entity Type:Organization
Organization Name:LONE STAR CIRCLE OF CARE
Other - Org Name:A.W. GRIMES MEDICAL OFFICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:PERIALAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:512-868-1124
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:512-868-9894
Practice Address - Street 1:2051 GATTIS SCHOOL RD
Practice Address - Street 2:SUITE 250
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7441
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:512-238-5492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE STAR CIRCLE OF CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-22
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206351301Medicaid
TX67-1901Medicare PIN