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NPI Code Detail

MEDICARE: SHAUN STARK

MEDICARE: SHAUN STARK
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
1172V00000XCommunity Health Worker
2175T00000XPeer Specialist

General Provider Information

NPI Number : 1861181711
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHAUN STARK
Provider Business Mailing Address
First Line : 2890 INLAND EMPIRE BLVD
Second Line :
City : ONTARIO
State : CA
Zip : 91764-4649
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2890 INLAND EMPIRE BLVD
Second Line :
City : ONTARIO
State : CA
Zip : 91764-4649
Country : US
Telephone Number : 909-233-7265
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/05/2023
Last Update Date : 05/19/2023

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Directions to “ SHAUN STARK ” Practice Location

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