1932608106 NPI number — STAR CLINIC LLC

Table of content: (NPI 1932608106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932608106 NPI number — STAR CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR CLINIC 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:
1932608106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 72300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85050-1022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-271-8666
Provider Business Mailing Address Fax Number:
623-271-8666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14155 N 83RD AVE STE 138
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-271-8666
Provider Business Practice Location Address Fax Number:
623-271-9229
Provider Enumeration Date:
02/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
YEGANEH
Authorized Official First Name:
TARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
623-271-8666

Provider Taxonomy Codes

  • Taxonomy code: 207VF0040X , with the licence number:  38152 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 335672 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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