MEDICARE: CAPITAL CITY SHINING STARS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	251C00000X	Developmentally Disabled Services Day Training Agency
3	320800000X	Mental Illness Community Based Residential Treatment Facility
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1326675497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL CITY SHINING STARS

Provider Business Mailing Address
First Line	:	PO BOX 1870
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-9108
Country	:	US
Telephone Number	:	804-715-2621
Fax Number	:	804-800-4250

Provider Business Practice Location Address
First Line	:	1201 COMMERCE ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-2904
Country	:	US
Telephone Number	:	804-715-2621
Fax Number	:	804-800-4250

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ALICIA STAR WILLS
Credential	:
Telephone Number	:	804-715-2621

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	05/29/2024

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Directions to “CAPITAL CITY SHINING STARS ” Practice Location

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