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General NPI Number Information
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NPI Number | 1891534541
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Entity Type | Individual
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Provider Name | MICHAEL ANDRE NUSTAR
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Gender | Male
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Dates
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Enumeration Date | 05/22/2024
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 108 MEDICINE COVE
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City | LOUISBURG
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State | NC
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Zip | 27549
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Country | US
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Telephone | 984-212-3065
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Fax |
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Provider Business Mailing Address
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Address Line | 1033 LAKE ROYALE
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City | LOUISBURG
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State | NC
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Zip | 27549-7028
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Country | US
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Telephone | 984-212-3065
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State | NC
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