Basic Information
| Provider Information | |||||||||
| NPI: | 1124505920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AUSTIN REGIONAL CLINIC, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARC - NOW CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 E US HWY 290 | ||||||||
| Address2: | SUITE 420 - CREDENTIALING | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787231098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123363802 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E WHITESTONE BLVD | ||||||||
| Address2: | BLDG B | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786139040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122593467 | ||||||||
| FaxNumber: | 5124067303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | DAGHESTANI | ||||||||
| AuthorizedOfficialFirstName: | ANAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5122315500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1333940-07 | 05 | TX | MEDICAID |