=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669005732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEYOND THE STARS EARLY INTERVENTION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2020
-----------------------------------------------------
Last Update Date | 02/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3871 DEWEY COX RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29560-7584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-389-3228
-----------------------------------------------------
Fax | 843-389-3229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 455
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29560-0455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-373-8140
-----------------------------------------------------
Fax | 843-389-3229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. WENDY S COX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-373-8140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------