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General NPI Number Information
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NPI Number | 1326675497
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Entity Type | Organization
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Legal Business Name | CAPITAL CITY SHINING STARS
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 05/29/2024
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Provider Practice Location Address
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Address Line | 1201 COMMERCE ST
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City | PETERSBURG
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State | VA
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Zip | 23803-2904
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Country | US
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Telephone | 804-715-2621
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Fax | 804-800-4250
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Provider Business Mailing Address
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Address Line | PO BOX 1870
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City | CHESTERFIELD
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State | VA
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Zip | 23832-9108
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Country | US
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Telephone | 804-715-2621
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Fax | 804-800-4250
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ALICIA STAR WILLS
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Credential |
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Telephone | 804-715-2621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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