Healthcare Provider Details

I. General information

NPI: 1255897799
Provider Name (Legal Business Name): AMANDA STAR DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2723 LINCOLN BLVD
SANTA MONICA CA
90405-4621
US

IV. Provider business mailing address

1912 N NEW HAMPSHIRE AVE
LOS ANGELES CA
90027-1819
US

V. Phone/Fax

Practice location:
  • Phone: 914-552-8687
  • Fax:
Mailing address:
  • Phone: 914-552-8687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number34456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: