Provider Demographics
NPI:1699838201
Name:STAR HAVEN INC.
Entity Type:Organization
Organization Name:STAR HAVEN INC.
Other - Org Name:SULPHUR OPTICAL SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-625-5665
Mailing Address - Street 1:4024 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6354
Mailing Address - Country:US
Mailing Address - Phone:337-625-5665
Mailing Address - Fax:337-625-5665
Practice Address - Street 1:4024 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6354
Practice Address - Country:US
Practice Address - Phone:337-625-5665
Practice Address - Fax:337-625-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1437751Medicaid