Basic Information
| Provider Information | |||||||||
| NPI: | 1184748915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUBACUTE TREATMENT FOR ADOLESCENT REHABILITATION SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STARS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 545 ESTUDILLO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945774611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103529200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 545 ESTUDILLO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945774611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103529200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNLAP | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CHIEF EXECUTIVE OFFIC | ||||||||
| AuthorizedOfficialTelephone: | 3102216336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 07DF | 01 | CA | CONTRA COSTA PROVIDER # | OTHER | 2006-40002112 | 01 | CA | CITY OF RICHMOND BIZ LIC | OTHER | 97392 | 01 | CA | CONTRA COSTA CNTY RPT # | OTHER |