Basic Information
Provider Information | |||||||||
NPI: | 1508224486 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STARS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STARS COMMUNITY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 545 ESTUDILLO AVE | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 945774611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103529200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17115 MEEKLAND AVE | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945411304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103174500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2016 | ||||||||
LastUpdateDate: | 03/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUNLAP | ||||||||
AuthorizedOfficialFirstName: | KENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CHIEF EXECUTIVE OFFIC | ||||||||
AuthorizedOfficialTelephone: | 3102216336 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.