=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669247946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY STAR BEHAVIORAL HEALTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2023
-----------------------------------------------------
Last Update Date | 11/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12240 HESPERIA RD STE A
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-8309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-245-8837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12240 HESPERIA RD STE A
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-8309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-245-8837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CHIEF EXECUTIVE OFFIC
-----------------------------------------------------
Name | KENT DUNLAP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-221-6336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------