Healthcare Provider Details

I. General information

NPI: 1649192550
Provider Name (Legal Business Name): STAR CITY DREAM OASIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 WELLSLEY ST NW
ROANOKE VA
24017-3032
US

IV. Provider business mailing address

1402 WELLSLEY ST NW
ROANOKE VA
24017-3032
US

V. Phone/Fax

Practice location:
  • Phone: 540-797-8096
  • Fax: 540-265-0986
Mailing address:
  • Phone: 540-797-8096
  • Fax: 540-265-0986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: DERRICK ALEXANDER RUBEN
Title or Position: CEO
Credential: QMHP
Phone: 540-797-8096