Healthcare Provider Details

I. General information

NPI: 1811024789
Provider Name (Legal Business Name): STARLIGHT ADOLESCENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5858 PADDON CIR
SAN JOSE CA
95123-3522
US

IV. Provider business mailing address

5858 PADDON CIR
SAN JOSE CA
95123-3522
US

V. Phone/Fax

Practice location:
  • Phone: 408-629-5048
  • Fax:
Mailing address:
  • Phone: 408-629-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number32240
License Number StateCA

VIII. Authorized Official

Name: MRS. VICTORIA REMI OYEWOLE
Title or Position: LPT
Credential: LPT
Phone: 408-661-9236