Provider Demographics
NPI:1992223309
Name:STELLAR HEALING LP
Entity Type:Organization
Organization Name:STELLAR HEALING LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:503-740-4772
Mailing Address - Street 1:105 MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3729
Mailing Address - Country:US
Mailing Address - Phone:503-740-4772
Mailing Address - Fax:
Practice Address - Street 1:2840 PARK AVE
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2866
Practice Address - Country:US
Practice Address - Phone:503-740-4772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14879171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty