Basic Information
| Provider Information | |||||||||
| NPI: | 1306938402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARLIGHT ADOLESCENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SILICON VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951381858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082849000 | ||||||||
| FaxNumber: | 4082849048 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 SILICON VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951381858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082849000 | ||||||||
| FaxNumber: | 4082849048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GROSS | ||||||||
| AuthorizedOfficialFirstName: | MARY JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5106359705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 43AG | 01 | CA | SANTA CLARA CTY. MED PROV | OTHER | 2215524 | 01 | CA | STATE CORP # | OTHER |