MEDICARE: S.T.A.R. CARE SERVICES, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1710464086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S.T.A.R. CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	601 EAST TABER STREET
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803
Country	:	US
Telephone Number	:	260-702-0925
Fax Number	:	260-702-0925

Provider Business Practice Location Address
First Line	:	601 E TABER ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-2408
Country	:	US
Telephone Number	:	260-702-0925
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. TEI FERGUSON
Credential	:
Telephone Number	:	260-446-7613

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	03/16/2021

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