Healthcare Provider Details

I. General information

NPI: 1902490600
Provider Name (Legal Business Name): STARSHIP MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 N AVALON BLVD
WILMINGTON CA
90744-1432
US

IV. Provider business mailing address

1703 N AVALON BLVD
WILMINGTON CA
90744-1432
US

V. Phone/Fax

Practice location:
  • Phone: 310-233-9355
  • Fax: 310-233-2545
Mailing address:
  • Phone: 818-518-5980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: EDDIE SANTIAGO
Title or Position: ADMINISTRATOR
Credential:
Phone: 818-610-9360