=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487154597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE STAR ASSESSMENT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2018
-----------------------------------------------------
Last Update Date | 02/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2135 47 STREET SUITE 2
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-867-2143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2135 47TH STREET SUITE 2
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-867-2143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN VILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-867-2143
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355A2700X
-----------------------------------------------------
Taxonomy Name | Audiology Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1201X
-----------------------------------------------------
Taxonomy Name | Optometric Assistant Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------