1174317754 NPI number — GROUNDED STARS LLC

Table of content: (NPI 1174317754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174317754 NPI number — GROUNDED STARS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROUNDED STARS 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:
1174317754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 FIFTH AVENUE, 4TH FLOOR
Provider Second Line Business Mailing Address:
#1021
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-294-4639
Provider Business Mailing Address Fax Number:
917-277-7178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 AMSTERDAM AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-294-4639
Provider Business Practice Location Address Fax Number:
917-277-7178
Provider Enumeration Date:
04/08/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
KIERRA
Authorized Official Middle Name:
ELSIE
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
803-280-6982

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 405300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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