MEDICARE: NORTH STAR CENTER, 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	51933	UT
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility	39297	UT
3	323P00000X	Psychiatric Residential Treatment Facility	39297	UT

General Provider Information

NPI Number	:	1821512583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH STAR CENTER, LLC.

Provider Business Mailing Address
First Line	:	55 N STATE ST # 555
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-8001
Country	:	US
Telephone Number	:	800-635-0165
Fax Number	:

Provider Business Practice Location Address
First Line	:	254 S STATE ST STE A
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5633
Country	:	US
Telephone Number	:	800-635-0165
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JOE AHQUIN SR.
Credential	:
Telephone Number	:	435-229-4889

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	06/16/2018

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