Healthcare Provider Details

I. General information

NPI: 1538708433
Provider Name (Legal Business Name): BRIGHT STAR HEALTHCARE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 PENNSYLVANIA AVE
MCDONOUGH GA
30253-9114
US

IV. Provider business mailing address

1545 PENNSYLVANIA AVE
MCDONOUGH GA
30253-9114
US

V. Phone/Fax

Practice location:
  • Phone: 470-781-1630
  • Fax:
Mailing address:
  • Phone: 470-781-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MARLON LLOYD
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 470-781-1630