Healthcare Provider Details

I. General information

NPI: 1356181515
Provider Name (Legal Business Name): STAR QUALITY DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 E TRINITY BLVD # A5A6
MONTGOMERY AL
36106-2897
US

IV. Provider business mailing address

1565 E TRINITY BLVD
MONTGOMERY AL
36106-2897
US

V. Phone/Fax

Practice location:
  • Phone: 334-314-5691
  • Fax:
Mailing address:
  • Phone: 334-669-9574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ANSENIO CLARK
Title or Position: OWNER
Credential:
Phone: 334-669-8574