Healthcare Provider Details

I. General information

NPI: 1932608106
Provider Name (Legal Business Name): STAR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 04/27/2025
Certification Date: 04/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 N 83RD AVE STE 138
PEORIA AZ
85381-5652
US

IV. Provider business mailing address

PO BOX 72300
PHOENIX AZ
85050-1022
US

V. Phone/Fax

Practice location:
  • Phone: 623-271-8666
  • Fax: 623-271-9229
Mailing address:
  • Phone: 623-271-8666
  • Fax: 623-271-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number38152
License Number StateAZ

VIII. Authorized Official

Name: MS. TARA YEGANEH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 623-271-8666