1407818842 NPI number — STARLIGHT MEDICAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407818842 NPI number — STARLIGHT MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STARLIGHT MEDICAL 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:
6
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:
1407818842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1602 NEWPORT GAP PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-6208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-633-5840
Provider Business Mailing Address Fax Number:
302-633-5844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5584 KIRKWOOD HWY
Provider Second Line Business Practice Location Address:
ORCHARD COMMONS
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19808-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-472-2121
Provider Business Practice Location Address Fax Number:
302-472-2120
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TADROS
Authorized Official First Name:
GAMAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
302-472-2121

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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