Basic Information
| Provider Information | |||||||||
| NPI: | 1669613972 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAR OF CA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4880 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056447827 | ||||||||
| FaxNumber: | 8776447545 | ||||||||
| Practice Location | |||||||||
| Address1: | 4880 MARKET ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056447827 | ||||||||
| FaxNumber: | 8776447545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2009 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOES | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | RAYMOND | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8056447827 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.