Healthcare Provider Details

I. General information

NPI: 1821165192
Provider Name (Legal Business Name): MARIE STAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11471 NW 35TH ST
SUNRISE FL
33323-1419
US

IV. Provider business mailing address

11471 NW 35TH ST
SUNRISE FL
33323-1419
US

V. Phone/Fax

Practice location:
  • Phone: 954-742-6349
  • Fax: 954-749-8560
Mailing address:
  • Phone: 954-742-6349
  • Fax: 954-749-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number10-1215GH
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number10-1215GH
License Number StateFL

VIII. Authorized Official

Name: MRS. MARIE-STUART DERAVILE
Title or Position: PRESIDENT
Credential:
Phone: 954-742-6349