=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609601897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT STAR HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2024
-----------------------------------------------------
Last Update Date | 09/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 MILLTOWN RD
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-336-0421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 MILLTOWN RD
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-501-7563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-CEO
-----------------------------------------------------
Name | JUSTIN K WILSON
-----------------------------------------------------
Credential | PHD-C, NP
-----------------------------------------------------
Telephone | 732-501-7563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------