Provider Demographics
NPI:1811024789
Name:STARLIGHT ADOLESCENT
Entity Type:Organization
Organization Name:STARLIGHT ADOLESCENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:REMI
Authorized Official - Last Name:OYEWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:408-661-9236
Mailing Address - Street 1:5858 PADDON CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3522
Mailing Address - Country:US
Mailing Address - Phone:408-629-5048
Mailing Address - Fax:
Practice Address - Street 1:5858 PADDON CIR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3522
Practice Address - Country:US
Practice Address - Phone:408-629-5048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32240320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness