Provider Demographics
NPI:1104271576
Name:LAURENCE ROBERT BOWER III
Entity type:Organization
Organization Name:LAURENCE ROBERT BOWER III
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-632-7562
Mailing Address - Street 1:19A GRUENE PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-2484
Mailing Address - Country:US
Mailing Address - Phone:830-632-7562
Mailing Address - Fax:830-632-6793
Practice Address - Street 1:207B SIDNEY BAKER STREET S
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028
Practice Address - Country:US
Practice Address - Phone:830-496-3058
Practice Address - Fax:830-496-3034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAURENCE ROBERT BOWER III
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-04
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0971DCOtherBCBS
TX365018602Medicaid