1922136498 NPI number — THE FOUNDATION FOR THE S.T.A.R.S.

Table of content: (NPI 1922136498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922136498 NPI number — THE FOUNDATION FOR THE S.T.A.R.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FOUNDATION FOR THE S.T.A.R.S.
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:
1922136498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530063
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89053-0063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-289-0157
Provider Business Mailing Address Fax Number:
702-892-0938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3708 WATERHOLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89130-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-515-1761
Provider Business Practice Location Address Fax Number:
702-515-1761
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
TRUDY
Authorized Official Middle Name:
ANISE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
702-289-0157

Provider Taxonomy Codes

  • Taxonomy code: 261QC1800X , with the licence number:  GF-125401040-0001 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100511029 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100511030 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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