Provider Demographics
NPI:1184297822
Name:BRIGHT STAR MEMORY CARE LLC
Entity type:Organization
Organization Name:BRIGHT STAR MEMORY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-498-1879
Mailing Address - Street 1:2 LAKEWAY PL
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 LAKEWAY PL
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-4781
Practice Address - Country:US
Practice Address - Phone:240-498-1879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care