Provider Demographics
NPI:1578235560
Name:HILLYSTAR LLC
Entity Type:Organization
Organization Name:HILLYSTAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TOLULOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRISU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-202-6375
Mailing Address - Street 1:5802 ANNAPOLIS RD APT 203
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2015
Mailing Address - Country:US
Mailing Address - Phone:202-840-3655
Mailing Address - Fax:
Practice Address - Street 1:5800 ANNAPOLIS RD # H2
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-2005
Practice Address - Country:US
Practice Address - Phone:202-840-3655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1508538570Medicaid