1053355446 NPI number — STAR HEALTHCARE LLC

Table of content: (NPI 1053355446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053355446 NPI number — STAR HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR HEALTHCARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053355446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 TAMIAMI TRL S STE 401B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34285-5562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-887-5633
Provider Business Mailing Address Fax Number:
860-887-5699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 TAMIAMI TRL S STE 401B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-5562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-887-5633
Provider Business Practice Location Address Fax Number:
860-887-5699
Provider Enumeration Date:
06/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HELMINSKI
Authorized Official First Name:
IVANA
Authorized Official Middle Name:
KATARYNA
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
860-887-5633

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: C10664 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004247989 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82-00812 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".