Provider Demographics
NPI:1336361633
Name:DAYSTAR RESIDENTIAL, INC.
Entity Type:Organization
Organization Name:DAYSTAR RESIDENTIAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:SALLS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:281-489-3054
Mailing Address - Street 1:3926 BAHLER AVE
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2823
Mailing Address - Country:US
Mailing Address - Phone:281-489-0317
Mailing Address - Fax:281-489-1800
Practice Address - Street 1:3926 BAHLER AVE
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-2823
Practice Address - Country:US
Practice Address - Phone:281-489-0317
Practice Address - Fax:281-489-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX516827320600000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherRTC