Healthcare Provider Details

I. General information

NPI: 1457041782
Provider Name (Legal Business Name): HOUSE OF STARS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 W WASHINGTON AVE
NAVASOTA TX
77868-2851
US

IV. Provider business mailing address

1105 W WASHINGTON AVE
NAVASOTA TX
77868-2851
US

V. Phone/Fax

Practice location:
  • Phone: 936-419-6015
  • Fax:
Mailing address:
  • Phone: 936-419-6015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: RONNIE WELLS
Title or Position: PROGRAM MANAGER
Credential:
Phone: 936-499-9696