Provider Demographics
NPI:1881790525
Name:LONE STAR FAMILY MEDICINE
Entity type:Organization
Organization Name:LONE STAR FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:870-389-0884
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6143
Mailing Address - Country:US
Mailing Address - Phone:940-627-8982
Mailing Address - Fax:940-627-7597
Practice Address - Street 1:803 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-3006
Practice Address - Country:US
Practice Address - Phone:870-389-0884
Practice Address - Fax:870-389-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N495Medicare PIN