Provider Demographics
NPI:1336769322
Name:SHININGSTAR INDEPENDENT LLC
Entity Type:Organization
Organization Name:SHININGSTAR INDEPENDENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:OLUFUNMILAYO
Authorized Official - Last Name:AJAYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-374-2292
Mailing Address - Street 1:5146 N 11TH AVE APT D208
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2161
Mailing Address - Country:US
Mailing Address - Phone:240-374-2292
Mailing Address - Fax:
Practice Address - Street 1:5146 N 11TH AVE APT D208
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2161
Practice Address - Country:US
Practice Address - Phone:240-374-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health