Basic Information
| Provider Information | |||||||||
| NPI: | 1639517097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | S.T.A.R.S, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STARS COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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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: | 1570 WARD ST | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103529200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | DEMETRIUS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | IT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5107465147 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STARS BEHAVIORAL HEALTH GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8195 | 01 | CA | ACBHCS PROVIDER | OTHER |