Provider Demographics
NPI:1912502477
Name:MIRA STAR ENTERPRISES LLC
Entity Type:Organization
Organization Name:MIRA STAR ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:FATI
Authorized Official - Middle Name:
Authorized Official - Last Name:MORO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:614-772-4391
Mailing Address - Street 1:3404 MANCHESTER WAY DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8877
Mailing Address - Country:US
Mailing Address - Phone:614-772-4391
Mailing Address - Fax:
Practice Address - Street 1:3404 MANCHESTER WAY DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8877
Practice Address - Country:US
Practice Address - Phone:614-772-4391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0379003Medicaid