Provider Demographics
NPI:1134226160
Name:SHINING STAR
Entity type:Organization
Organization Name:SHINING STAR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HAQQ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-978-8599
Mailing Address - Street 1:PO BOX 2744
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-2744
Mailing Address - Country:US
Mailing Address - Phone:910-904-6699
Mailing Address - Fax:910-904-1879
Practice Address - Street 1:378 APPALOOSA DR
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-8504
Practice Address - Country:US
Practice Address - Phone:910-904-6699
Practice Address - Fax:910-904-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-043-045322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603538Medicaid