Healthcare Provider Details

I. General information

NPI: 1952840183
Provider Name (Legal Business Name): GLOBE STAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 S IRONWOOD DR
SOUTH BEND IN
46615-1613
US

IV. Provider business mailing address

621 BROADWAY
CHESTERTON IN
46304-2259
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-5492
  • Fax: 219-921-0143
Mailing address:
  • Phone: 219-921-5492
  • Fax: 219-921-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. ANTHONY M MCCROVITZ
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 219-921-5492