Provider Demographics
NPI:1942565627
Name:STAR HEALTHCARE REGISTRY
Entity Type:Organization
Organization Name:STAR HEALTHCARE REGISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VALERIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-918-4669
Mailing Address - Street 1:PO BOX 13993
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3993
Mailing Address - Country:US
Mailing Address - Phone:601-918-4669
Mailing Address - Fax:
Practice Address - Street 1:113 MAXWELL CV
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-9514
Practice Address - Country:US
Practice Address - Phone:601-918-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP320903164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty