Basic Information
| Provider Information | |||||||||
| NPI: | 1750911376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STELLA MARIS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 WINSLOW AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441132336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167272086 | ||||||||
| FaxNumber: | 2167711563 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441132333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167272086 | ||||||||
| FaxNumber: | 2167711563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2020 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | GACEK | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EMR ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2167272086 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.