Provider Demographics
NPI:1508036450
Name:STAR LIGHT HOME HEALTH
Entity Type:Organization
Organization Name:STAR LIGHT HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WYSPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1703-435-8304
Mailing Address - Street 1:409 N FREDONIA ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6466
Mailing Address - Country:US
Mailing Address - Phone:903-985-6084
Mailing Address - Fax:
Practice Address - Street 1:409 N FREDONIA ST
Practice Address - Street 2:SUITE 114
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6466
Practice Address - Country:US
Practice Address - Phone:903-985-6084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX747197OtherMEDICARE HOME HEALTH PROVIDER NUMBER