MEDICARE: STARR LIGHT EXPRESS

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	343900000X	Non-emergency Medical Transport (VAN)
2	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1689310674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STARR LIGHT EXPRESS

Provider Business Mailing Address
First Line	:	815 MYRTLE ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5530
Country	:	US
Telephone Number	:	707-348-2294
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 MYRTLE ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5530
Country	:	US
Telephone Number	:	707-348-2294
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	JASON FRUTH
Credential	:
Telephone Number	:	707-348-2294

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	12/28/2022

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Directions to “STARR LIGHT EXPRESS ” Practice Location

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