Healthcare Provider Details

I. General information

NPI: 1326584632
Provider Name (Legal Business Name): RENEE STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 PLACER BULLION AVE
LAS VEGAS NV
89178-6200
US

IV. Provider business mailing address

9131 PLACER BULLION AVE
LAS VEGAS NV
89178-6200
US

V. Phone/Fax

Practice location:
  • Phone: 909-618-7393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86020783
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: