Provider Demographics
NPI:1821165192
Name:MARIE STAR, INC.
Entity Type:Organization
Organization Name:MARIE STAR, INC.
Other - Org Name:STUIE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE-STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAVILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-742-6349
Mailing Address - Street 1:11471 NW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-1419
Mailing Address - Country:US
Mailing Address - Phone:954-742-6349
Mailing Address - Fax:954-749-8560
Practice Address - Street 1:11471 NW 35TH ST
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-1419
Practice Address - Country:US
Practice Address - Phone:954-742-6349
Practice Address - Fax:954-749-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-1215GH320900000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686881996Medicaid
FL686881997Medicaid