Provider Demographics
NPI:1326432527
Name:VALLEY STAR CRT - 'THE STAY'
Entity Type:Organization
Organization Name:VALLEY STAR CRT - 'THE STAY'
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-763-4760
Mailing Address - Street 1:780 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-1003
Mailing Address - Country:US
Mailing Address - Phone:909-763-4760
Mailing Address - Fax:
Practice Address - Street 1:780 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1003
Practice Address - Country:US
Practice Address - Phone:909-763-4760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness