Provider Demographics
NPI:1144504614
Name:BEADED STAR RECOVERY, LLC
Entity type:Organization
Organization Name:BEADED STAR RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:904-270-1234
Mailing Address - Street 1:2380 3RD ST S STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4023
Mailing Address - Country:US
Mailing Address - Phone:904-270-1234
Mailing Address - Fax:
Practice Address - Street 1:2380 3RD ST S STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4023
Practice Address - Country:US
Practice Address - Phone:904-270-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center