Provider Demographics
NPI:1679620132
Name:ALLEGHANY STAR GROUP, LLC
Entity Type:Organization
Organization Name:ALLEGHANY STAR GROUP, LLC
Other - Org Name:ALLEGHANY STAR THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:336-372-7887
Mailing Address - Street 1:PO BOX 1925
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-1925
Mailing Address - Country:US
Mailing Address - Phone:336-372-7887
Mailing Address - Fax:336-372-7887
Practice Address - Street 1:295 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675
Practice Address - Country:US
Practice Address - Phone:336-372-7887
Practice Address - Fax:336-372-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC791225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2510813Medicare PIN