Provider Demographics
NPI:1689138604
Name:PROTOSTAR LLC
Entity Type:Organization
Organization Name:PROTOSTAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIPPES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-289-4933
Mailing Address - Street 1:2080 N STATE HIGHWAY 360 STE 230
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-0900
Mailing Address - Country:US
Mailing Address - Phone:214-289-4933
Mailing Address - Fax:
Practice Address - Street 1:2080 N STATE HIGHWAY 360 STE 230
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-0900
Practice Address - Country:US
Practice Address - Phone:682-888-1290
Practice Address - Fax:940-312-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health