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General NPI Number Information
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NPI Number | 1255118386
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Entity Type | Organization
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Legal Business Name | STAR QUALITY OUTCOMES CLINIC
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Dates
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Enumeration Date | 09/12/2023
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Last Update Date | 09/20/2023
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Provider Practice Location Address
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Address Line | 7632 TRAILVIEW DR
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City | GONZALES
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State | LA
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Zip | 70737-8274
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Country | US
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Telephone | 225-445-9049
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Fax |
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Provider Business Mailing Address
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Address Line | 7632 TRAILVIEW DR
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City | GONZALES
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State | LA
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Zip | 70737-8274
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Country | US
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Telephone | 225-445-9049
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | JEROME GRANT JR.
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Credential |
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Telephone | 225-828-7070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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