=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649192550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAR CITY DREAM OASIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2026
-----------------------------------------------------
Last Update Date | 07/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1402 WELLSLEY ST NW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24017-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-797-8096
-----------------------------------------------------
Fax | 540-265-0986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1402 WELLSLEY ST NW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24017-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-797-8096
-----------------------------------------------------
Fax | 540-265-0986
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DERRICK ALEXANDER RUBEN
-----------------------------------------------------
Credential | QMHP
-----------------------------------------------------
Telephone | 540-797-8096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------