Provider Demographics
NPI:1578208724
Name:STAR HEALTH CLUB LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:STAR HEALTH CLUB LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:502-214-3210
Mailing Address - Street 1:4400 BRECKENRIDGE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4082
Mailing Address - Country:US
Mailing Address - Phone:502-214-3210
Mailing Address - Fax:
Practice Address - Street 1:4400 BRECKENRIDGE LN STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4082
Practice Address - Country:US
Practice Address - Phone:502-214-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities