Provider Demographics
NPI:1255118386
Name:STAR QUALITY OUTCOMES CLINIC
Entity type:Organization
Organization Name:STAR QUALITY OUTCOMES CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-828-7070
Mailing Address - Street 1:7632 TRAILVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8274
Mailing Address - Country:US
Mailing Address - Phone:225-445-9049
Mailing Address - Fax:
Practice Address - Street 1:7632 TRAILVIEW DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8274
Practice Address - Country:US
Practice Address - Phone:225-445-9049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service