Provider Demographics
NPI:1790037224
Name:STAR MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:STAR MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-269-5541
Mailing Address - Street 1:605 SE PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4308
Mailing Address - Country:US
Mailing Address - Phone:360-269-5541
Mailing Address - Fax:866-874-1472
Practice Address - Street 1:1217 MELLEN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1175
Practice Address - Country:US
Practice Address - Phone:360-740-8546
Practice Address - Fax:866-874-1472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center