Provider Demographics
NPI:1780757310
Name:LONE STAR OPTICAL INC.
Entity type:Organization
Organization Name:LONE STAR OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:BICKELMAN
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-641-2246
Mailing Address - Street 1:109 S PARK DR
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-5917
Mailing Address - Country:US
Mailing Address - Phone:325-641-2246
Mailing Address - Fax:325-641-0864
Practice Address - Street 1:109 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5917
Practice Address - Country:US
Practice Address - Phone:325-641-2246
Practice Address - Fax:325-641-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81520NOtherBCBS
TX152777201Medicaid
TX152777201Medicaid
TX=========OtherTAX ID #
TX81520NOtherBCBS