Healthcare Provider Details

I. General information

NPI: 1659678480
Provider Name (Legal Business Name): SHINING STAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 CADILLAC BLVD
DETROIT MI
48214-3105
US

IV. Provider business mailing address

PO BOX 15122
DETROIT MI
48215-0122
US

V. Phone/Fax

Practice location:
  • Phone: 313-377-1849
  • Fax: 313-557-2751
Mailing address:
  • Phone: 313-377-1849
  • Fax: 313-557-2751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE WATT
Title or Position: CEO
Credential:
Phone: 313-377-1849