MEDICARE: SHINING STAR LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1659678480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING STAR LLC

Provider Business Mailing Address
First Line	:	PO BOX 15122
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48215-0122
Country	:	US
Telephone Number	:	313-377-1849
Fax Number	:	313-557-2751

Provider Business Practice Location Address
First Line	:	1325 CADILLAC BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-3105
Country	:	US
Telephone Number	:	313-377-1849
Fax Number	:	313-557-2751

Authorized Official
Title or Position	:	CEO
Name	:	MS. STEPHANIE WATT
Credential	:
Telephone Number	:	313-377-1849

Provider Enumeration Date	:	02/14/2011
Last Update Date	:	06/03/2016

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Directions to “SHINING STAR LLC ” Practice Location

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