MEDICARE: SHINING STAR COMMUNITY HEALTH 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1760966220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING STAR COMMUNITY HEALTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	3601 GREEN HOLLOW DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-6716
Country	:	US
Telephone Number	:	972-589-8580
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 GREEN HOLLOW DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-6716
Country	:	US
Telephone Number	:	972-589-8580
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. NEAL E CROSS
Credential	:	MBA
Telephone Number	:	972-589-8580

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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