=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588906424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAR PRIVATE CARE SERVICES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2013
-----------------------------------------------------
Last Update Date | 03/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 728 23RD ST
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23607-4614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-504-0660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 140
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23607-0140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-504-0660
-----------------------------------------------------
Fax | 757-825-0305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | IDELL MICHELLE VINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-753-3153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------