Healthcare Provider Details

I. General information

NPI: 1639618564
Provider Name (Legal Business Name): RENEE STARR LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2017
Last Update Date: 02/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8695 ARCHER AVE UNIT #13
WILLOW SPRINGS IL
60480-1260
US

IV. Provider business mailing address

8695 ARCHER AVE UNIT #13
WILLOW SPRINGS IL
60480-1260
US

V. Phone/Fax

Practice location:
  • Phone: 708-702-5056
  • Fax:
Mailing address:
  • Phone: 708-702-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.010585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: