=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023460342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 5 STAR RESIDENTIAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 05/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5024 KELSO ST
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-2391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-926-0133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3116 BUNCH WALNUTS RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-204-4655
-----------------------------------------------------
Fax | 757-282-2697
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SAMUEL BAPTIST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-926-0133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------