1275995631 NPI number — SEA STARS THERAPY

Table of content: (NPI 1275995631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275995631 NPI number — SEA STARS THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEA STARS THERAPY
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:
1275995631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 JOHNNIE DODDS BLVD
Provider Second Line Business Mailing Address:
STE 103-179
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-3135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-209-7174
Provider Business Mailing Address Fax Number:
843-556-6742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 JOHNNIE DODDS BLVD
Provider Second Line Business Practice Location Address:
STE 103-179
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-209-7174
Provider Business Practice Location Address Fax Number:
843-556-6742
Provider Enumeration Date:
03/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GUARIGLIA
Authorized Official First Name:
KARIN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-209-7174

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4188 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TH2677 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4188 . This is a "LICENSE" identifier . This identifiers is of the category "OTHER".




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