Healthcare Provider Details

I. General information

NPI: 1972989457
Provider Name (Legal Business Name): FIVE STAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WINDSOR CV SUITE 406
COLUMBIA SC
29223-1833
US

IV. Provider business mailing address

1 WINDSOR CV SUITE 406
COLUMBIA SC
29223-1833
US

V. Phone/Fax

Practice location:
  • Phone: 803-764-5877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JERVONTA WALKER
Title or Position: OWNER
Credential:
Phone: 803-920-3598