MEDICARE: DAYSTAR, INC

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	282J00000X	Religious Nonmedical Health Care Institution		FL

General Provider Information

NPI Number	:	1750389672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAYSTAR, INC

Provider Business Mailing Address
First Line	:	3800 S FLAMINGO RD
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-1616
Country	:	US
Telephone Number	:	954-473-0167
Fax Number	:	954-473-0202

Provider Business Practice Location Address
First Line	:	3800 S FLAMINGO RD
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-1616
Country	:	US
Telephone Number	:	954-473-0167
Fax Number	:	954-473-0202

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. BEVERLY ANN LUTIRELL
Credential	:
Telephone Number	:	954-473-0167

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/22/2020

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